Samter's Triad Research Articles

Anesthesia Management in a Patient Diagnosed with Kounis-Zavras Syndrome and Who has Brittle Asthma and Samter Triad

In Kounis-Zavras syndrome, vasospastic mediators released from mast cells as response to allergic stimulus lead to coronary vasospasm and result in acute coronary syndrome or angina pectoris. In this case report, anesthesia management in a 35 year old female patient with Kounis-Zavras syndrome who had Samter triad and multiple drug allergy and had arrest previously due to drug allergy and hence who has implantable cardioverter defibrillator is presented.

Aspirin sensitivity syndrome (Samter's Triad): An unrecognized disorder in children with nasal polyposis

Aspirin sensitivity syndrome is an underdiagnosed entity in pediatric otolaryngology. The diagnosis must be considered in a pediatric non-cystic fibrosis patient with florid nasal polyposis. In this small case series, we will describe 2 patient's presentation, work up, allergic and surgical therapies and their postoperative course. In doing so, we hope to increase awareness and to illustrate the details that are involved in its diagnosis and treatment.

Topical Gel Therapy for Sinonasal Polyposis in Samter's Triad: Preliminary Report

Rhinosinusitis and polyposis are difficult to treat in patients with Samter's triad; they commonly recur despite sinus surgery, antibiotics, and/or nasal steroids. The present study assesses the efficacy of a multimodal regimen that includes topical corticosteroids and antibiotics delivered through a hydroxyethyl cellulose gel and by nebulization. Eleven patients with Samter's triad who had polyposis and rhinosinusitis that recurred despite endoscopic sinus surgery were treated with a 6-week course of multimodal topical therapy consisting of a hydroxyethyl cellulose gel that releases corticosteroids and antibiotics, topical nebulization of corticosteroids and antibiotics, saline solution rinses, and sinus debridement. Clinical outcomes were evaluated by Lund-Kennedy endoscopic and symptom scores. Histologic assessment was evaluated by hematoxylin and eosin staining before and after treatment. Both Lund-Kennedy symptom and endoscopic scores showed.a progressive and statistically significant decline throughout the course of treatment, reaching at 6 weeks 42% of the pretreatment values (p = 0.005) for the Lund-Kennedy symptom score and 34% (p = 0.002) for the endoscopic score, respectively; however, the significance of the improvement was lost with time. Topical gel therapy improves clinical symptoms, endoscopic findings, and sinus membrane histologic features in patients with refractory Samter's triad, but the improvement is transient, suggesting that a longer therapeutic period might be needed.

Aspirin Exacerbated Respiratory Disease

Aspirin Exacerbated Respiratory Disease

Sinonasal outcome under aspirin desensitization following functional endoscopic sinus surgery in patients with aspirin triad

Recalcitrant forms of recurrent nasal polyposis are problematic for patients as for rhinosurgeons. In aspirin-sensitive patients, aspirin desensitization is supposed to prevent recurrence by targeting the metabolism of arachidonic acid. Aspirin-sensitive patients (n = 65) following aspirin desensitization after functional endoscopic sinus surgery (FESS) for recurrent nasal polyposis under daily intake of 500-mg aspirin were compared to a post-FESS group (n = 81) of aspirin-sensitive individuals using exclusively topical mometasone. Quality of life (QoL) scores including sinonasal, pulmonal and general QoL items as well as endoscopic endonasal examination findings were evaluated during the postoperative follow-up period. After a follow-up period of minimum 18 months, a significant improvement in nasal obstruction, rhinorrhea, post nasal drip, sense of smell, facial pain, sleep quality and further general QoL items in desensitized patients was found compared to aspirin-sensitive controls. Improvement in sinonasal symptoms was evident, whereas the severity of asthmatic symptoms showed no significant changes. Although the pathophysiology of aspirin sensitivity is still not fully understood and the therapy is not sufficiently investigated, aspirin desensitization seems to have a positive effect on QoL scores concerning sinonasal symptoms and should be regarded as a possible postoperative treatment modality for recurrent nasal polyposis in aspirin-sensitive individuals.

Immunomodulatory Treatments for Aspirin Exacerbated Respiratory Disease

Aspirin triad is a subclass of chronic sinusitis characterized by nasal polyposis, nonallergic induced asthma, and aspirin sensitivity. Also known as Samter's triad or aspirin-exacerbated respiratory disease, aspirin triad commonly affects the adult population and is seldom found in pediatric patients. This rhinosinusitis has multiple layers of pathological process, but the ultimate predicament is caused by cysteinyl leukotrienes (cysLTs). Pharmacotherapies include oral steroid, lipoxygenase inhibitor, and cysLT receptor inhibitor drugs, which can provide some relief for these patients. Immunomodulation via aspirin desensitization is considered when pharmacotherapy has failed. When aspirin triad is unmanageable with medical treatment alone, endoscopic sinus surgery with polypectomy can alleviate the patient's symptoms, allowing for a better response to postoperative medical management such as topical medication as well as delivery of topical medications.

Pancreatitis as a novel complication of aspirin therapy in patients with aspirin-exacerbated respiratory disease

Aspirin-exacerbated respiratory disease (AERD), previously termed Samter triad, is an adult-onset disease characterized by asthma, hyperplastic chronic sinusitis, nasal polyposis, and hypersensitivity to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). Although the upper and lower airway inflammation seen in patients with AERD is exacerbated by the ingestion of aspirin and other NSAIDs, the disease progresses independently of exposure to these medications. Since 1922, when this syndrome was originally identified by Widal,1 and 1967, when it was further described by Samter and Beers,2 the clinical efficacy of aspirin desensitization and ongoing aspirin therapy has been well established.

Postoperative Care for Samter's Triad Patients Undergoing Endoscopic Sinus Surgery: A Double-Blinded, Randomized Controlled Trial

Postoperative Care for Samter's Triad Patients Undergoing Endoscopic Sinus Surgery: A Double-Blinded, Randomized Controlled Trial

HLA-DRA Polymorphisms associated with Risk of Nasal Polyposis in Asthmatic Patients

Nasal polyps, part of the aspirin triad symptoms, are edematous protrusions arising from the mucosa of the nasal sinuses. Although the causative factors and pathogenesis of the polyps are unknown, the significant effect of human leukocyte antigen-DR (HLA-DR) expression in nasal polyps and genetic associations of the major histocompatibility complex class II, DR alpha (HLA-DRA) with immune-mediated diseases have been revealed. To investigate the associations of HLA-DRA polymorphisms with nasal polyposis in asthmatic patients and in aspirin-hypersensitive subgroups, 22 single nucleotide polymorphisms (SNPs) were genotyped in a total of 467 asthmatic patients including 158 nasal polyp-positive and 309 polyp-negative subjects. Statistical analysis showed that four SNPs (p = 0.0005-0.02; Pcorr = 0.009-0.033) and one haplotype (p = 0.002; Pcorr = 0.029) were significantly associated with the presence of nasal polyposis in asthmatic patients. In further analysis, although significant signals disappeared after corrections for multiple testing, two HLA-DRA polymorphisms (rs9268644C>A, rs3129878A>C) were found to be potential markers for nasal polyp development in aspirin-tolerant asthma (p = 0.005 and 0.007, respectively) compared with the aspirin-exacerbated respiratory disease (p > 0.05) subgroup. In silico analysis predicted major "C" allele of rs14004C>A in 5'-untranslated region as a potential binding site for regulatory glucocorticoid receptor. In addition, sequence nearby rs1051336G>A is suspected to be a pyrimidine-rich element that affects mRNA stability. Despite the need for replication in larger cohorts and/or functional evaluations, our findings suggest that HLA-DRA polymorphisms might contribute to nasal polyposis susceptibility in patients with asthma.

Influence of cigarette smoking on endoscopic sinus surgery long-term outcomes

Objective: The purpose of this study was to explore the influence of smoking on long-term outcomes of endoscopic sinus surgery for chronic rhinosinusitis. Methods: The study prospectively enrolled 274 patients at the Department of Otolaryngology of the Warsaw Medical University from 1993 to 2000. All patients were diagnosed with chronic rhinosinusitis and scheduled for the endoscopic sinus surgery. We evaluated subgroups of patients with respect to bronchial asthma, allergy, aspirin triad, gastro-esophageal reflux disease and nasal septal deviation. Patients were divided into smokers and non-smokers. Patient CT scan results were recorded according to the four-grade classification system by Kennedy. Patients were observed over a period between 2 to 9 years following the surgical intervention and had their surgery revised if the severity of symptoms were at the same level or worsened. Results: Prior to endoscopic sinus surgery, 23% of smokers and 20% of non-smokers scored III or IV on the Kennedy Scale. The revision ESS was carried out in 27 patients. In this group there were 20% smokers and 7% non-smokers, with the difference being significant. There was no significant difference in the postoperative quality of life scale scores. Conclusions: The study shows that while smoking did not influence preoperative symptoms, smokers had worse postoperative outcomes.

Influence of cigarette smoking on endoscopic sinus surgery long-term outcomes

Objective: The purpose of this study was to explore the influence of smoking on long-term outcomes of endoscopic sinus surgery for chronic rhinosinusitis. Methods: The study prospectively enrolled 274 patients at the Department of Otolaryngology of the Warsaw Medical University from 1993 to 2000. All patients were diagnosed with chronic rhinosinusitis and scheduled for the endoscopic sinus surgery. We evaluated subgroups of patients with respect to bronchial asthma, allergy, aspirin triad, gastro-esophageal reflux disease and nasal septal deviation. Patients were divided into smokers and non-smokers. Patient CT scan results were recorded according to the four-grade classification system by Kennedy. Patients were observed over a period between 2 to 9 years following the surgical intervention and had their surgery revised if the severity of symptoms were at the same level or worsened. Results: Prior to endoscopic sinus surgery, 23% of smokers and 20% of non-smokers scored III or IV on the Kennedy Scale. The revision ESS was carried out in 27 patients. In this group there were 20% smokers and 7% non-smokers, with the difference being significant. There was no significant difference in the postoperative quality of life scale scores. Conclusions: The study shows that while smoking did not influence preoperative symptoms, smokers had worse postoperative outcomes.

Influence of cigarette smoking on endoscopic sinus surgery long-term outcomes

The purpose of this study was to explore the influence of smoking on long-term outcomes of endoscopic sinus surgery for chronic rhinosinusitis. The study prospectively enrolled 274 patients at the Department of Otolaryngology of the Warsaw Medical University from 1993 to 2000. All patients were diagnosed with chronic rhinosinusitis and scheduled for the endoscopic sinus surgery. We evaluated subgroups of patients with respect to bronchial asthma, allergy, aspirin triad, gastro-esophageal reflux disease and nasal septal deviation. Patients were divided into smokers and non-smokers. Patient CT scan results were recorded according to the four-grade classification system by Kennedy. Patients were observed over a period between 2 to 9 years following the surgical intervention and had their surgery revised if the severity of symptoms were at the same level or worsened. Prior to endoscopic sinus surgery, 23% of smokers and 20% of non-smokers scored III or IV on the Kennedy Scale. The revision ESS was carried out in 27 patients. In this group there were 20% smokers and 7% non-smokers, with the difference being significant. There was no significant difference in the postoperative quality of life scale scores. The study shows that while smoking did not influence preoperative symptoms, smokers had worse postoperative outcomes.

Postoperative care for Samter's triad patients undergoing endoscopic sinus surgery: A double-blinded, randomized controlled trial

Evidence is lacking to guide the postoperative management of Samter's triad patients with chronic rhinosinusitis with polyposis (CRSwP) undergoing endoscopic sinus surgery (ESS). The purpose of this study was to compare three different standardized medication regimens prescribed to these patients after ESS. Three-arm, randomized, double-blinded, controlled trial. Patients with Samter's triad undergoing ESS were postoperatively randomized into three medication regimens, those being saline irrigation alone (control group A), saline irrigation plus separate budesonide nasal spray (group B), and saline irrigation mixed with budesonide nasal spray (group C). Outcome measures were Sino-Nasal Outcome Test scores, Lund-Mackay computed tomography scores, and Lund-Kennedy endoscopic scores taken at preoperative baseline, and then at 6 months and 1 year postoperatively. Side effect profiles were also measured (adrenocorticotropic hormone blood level ranges and intraocular pressure at the same interval points). Analysis of variance and χ(2) analyses were conducted using a Bonferroni correction method and routine descriptive statistics. Inter- and intragroup comparisons were made. Sixty subjects were recruited. All groups were equivalent at baseline in all outcomes. All intragroup analyses showed statistically and clinically significant improvement in disease status as compared to baseline (P < .0167), with a sustained but lessened improvement at 1 year. However, no statistically or clinically significant differences were observed between groups at any time point (P > .05). There was no treatment effect noted. In this study, nasal steroids did not confer any additional benefit over saline alone as post-ESS care for the Samter's triad CRSwP patient population.

Management of Refractory Nasal Polyposis in Samter’s Triad

Objective: Rhinosinusitis and polyposis in Samter triad is difficult to treat, commonly recurring despite sinus surgery, antibiotics, and/or nasal steroids. Systemic steroids are limited by side effects. The present study assesses the efficacy of a gel placed into the sinuses, releasing steroids and antibiotics, along with topical nebulization of the same medications. Method: Ten Samter patients with recurrent rhinosinusitis after sinus surgery received weekly intra-sinus placement of a hydroxycellulose gel-releasing mometasone and antibiotics, along with endoscopic sinus debridement, for 6 weeks. Outcome was evaluated by Lund-Kennedy (LK) endoscopic and symptom scales immediately, 3 weeks, 6 weeks, and 10 weeks after the beginning of the protocol. Results: Both LK symptoms and endoscopic scores showed a progressive and statistically significant decline throughout the course of therapy, reaching at the end of treatment 56% ( P = .003) and 59% ( P = .004) improvement of pretreatment values, respectively. At 1 month posttreatment, mild relapse was noted. Conclusion: A topical membrane therapy regimen consisting of gel-releasing corticosteroids and antibiotics, along with topically nebulized corticosteroids and antibiotics, regular saline hydrotherapy, and sinus debridement, improves symptoms and endoscopic findings in recurrent Samter sinonasal polyposis.

Bilateral Clinical Pathology of the Temporal Bone

Objectives/Hypothesis: The aim of this study is to indicate anatomic and immunologic peculiarities of the temporal bone which leave it vulnerable to traumatic, infectious and neoplastic insult. Study Design: Seven patients' cases are described in which the clinical pathology of the temporal bone was bilateral. The bilaterality of these cases serves to illustrate the anatomic points which are the focus of this study. Methods: This is a case series. Results: The seven paradigmatic cases are described and the relevant anatomy is explored. These are bilateral tuberculosis of the middle ear and mastoid, bilateral histiocytosis X, bilateral external canal amyloidosis, bilateral middle ear polyposis in Samter's triad, bilateral temporal bone fractures, bilateral middle cranial fossa encephaloceles, and bilateral congenital enlarged superior vestibular nerve canals. The thinness of the skull base, the many fluid-filled and tissue-filled canals which enter the temporal bone and the thinness of the tissues investing all the surfaces contribute to the temporal bone's vulnerability to trauma, infection and neoplasm. Conclusion: Cases of bilateral temporal bone pathology demonstrate the temporal bone's structural and immunologic weaknesses.

Revision Rates after Endoscopic Sinus Surgery: A Recurrence Analysis

Chronic rhinosinusitis with nasal polyposis is often refractory to medical and surgical management, especially in patients with asthma and aspirin intolerance. We used a contemporary database to investigate recurrence and revision surgery rates following endoscopic sinus surgery. We performed a cohort study using a survival analysis technique. Records were reviewed of 549 patients with nasal polyposis who underwent endoscopic sinus surgery over a 10-year period. The main outcome measure was disease-free and surgery-free survival following endoscopic sinus surgery, investigated with Kaplan-Meier analyses. Patients with Samter's triad were significantly more likely to have a recurrence and undergo a second surgery following recurrence (risk-odds ratio, 2.7; 95% confidence interval, 1.5 to 3.2; p < 0.01) than were patients without asthma or with only asthma from the triad. The presence of initial frontal sinus disease also increased the likelihood of revision surgery (risk-odds ratio, 1.6; 95% confidence interval, 1.2 to 1.8; p < 0.05). This is the first study to use survival analysis to document revision surgery rates following endoscopic sinus surgery. Revision surgery occurs at a high rate, especially in patients with asthma, Samter's triad, or frontal sinus disease. Patients should routinely be informed during clinical consultations about the likelihood of recurrence. Early intervention for frontal sinus disease may be considered.

Analgetikaintoleranz

The full clinical picture of aspirin intolerance - the association of aspirin-induced bronchial asthma, aspirin sensitivity and nasal polyps - has been described as Morbus Widal or later as the "Samter triad". Today the term Aspirin-exacerbated respiratory disease (AERD) is preferred to account for the progressive nature of this inflammatory airway condition with its unrelenting course even in the absence of non steroidal anti-inflammatory drugs (NSAID). This acquired idiosyncrasy appears to be related to an abnormal arachidonic acid metabolism. Epidemiological data suggests that 10% of all asthmatics do react with life-threatening asthma-attacks after the ingestion of aspirin (ASA) or other NSAID. Some asthmatics with nasal polyposis have been reported to suffer from aspirin intolerance. Although the exact mechanism is still unclear, it is unlikely that the pathogenesis is IgE-mediated. Patients often report chronic nasal obstruction, hyposmia, chronic rhinorrhoea, orbital edema and urticaria with flushing after the ingestion of NSAID. While a typical history and endoscopic findings can be suggestive of AERD, a definite diagnosis relies on appropriate challenge tests. AERD is often refractory to standard asthma treatment with systemic and inhaled steroids, β(2)-agonists, leukotrien-antagonists. Adaptive desactivation can induce a reversible tolerance to NSAID which also leads to an improvement in signs and symptoms of the underlying AERD.

Aspirin sensitivity and the nose

There is a well-recognized association of aspirin sensitivity, aspirin-induced asthma, nasal polyposis or sinusitis, known as Samter's triad. This article outlines the pathogenesis and clinical features of this condition and reviews current management options.

A Case of Tramadol Induced Asthma Attack in a Patient with Samter's Triad

Samter’s triad is a well known syndrome and is characterized by a triad of asthma, aspirin or NSAID sensitivity and chronic sinusitis with nasal polyp. Chronic sinusitis with Samter’s triad is difficult to treat completely and has poor prognosis. Tramadol is a non-opioid analgesic that rarely shows respiratory suppression and is known to be relatively safe because it does not inhibit prostaglandin synthesis. For that reason, patients with asthma may avoid drug-induced exacerbations of the disease by substituting Tramadol for NSAIDs. We experienced a case of asthma attack in a patient with Samter’s triad after Tramadol injection. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:121-5 Key WordsZZSamter’s triad·Tramadol·Asthma attack.

Methotrexate: Can it be a Choice for Nasal Polyposis in Aspirin Exacerbated Respiratory Disease?

Nasal polyposis (NP) is considered a subgroup of chronic rhinosinusitis and is commonly associated with asthma, bronchiectasis, and cystic fibrosis. A certain subgroup of nasal polyposis is known as Aspirin Exacerbated Respiratory Disease (AERD), previously called Samter's Triad or aspirin triad, comprising polyposis, asthma, and aspirin hypersensitivity and makes up almost 10% of cases of NP. Therapy of NP involves a combination of medical and surgical treatments. However, recurrences are common, particularly in patients with asthma and aspirin hypersensitivity. Both topical and systemic corticosteroids form the mainstay of conservative therapy for NP as well as a primary treatment and prevention for recurrences. They have been shown to improve nasal breathing, rhinitis symptoms, and reduce the size of NP, along with the rate of recurrence. There is great concern about the adverse effects of systemic steroids, especially when long-term usage is necessary to maintain improvement. So far, no knowledge exists about the effects of methotrexate (MTX) on NP of the patients with asthma. We report two patients whose NP dramatically reduced in size after a course of MTX therapy administered as an additional treatment for their steroid- dependent asthma.