Endoscopic Sinus Surgery Decreases Asthma in Aspirin Triad Disease

Negative reactions to aspirin are relatively rare in the healthy population (around 0.3 percent). However, there is a substantial number of patients who have the so-called "aspirin triad disease (ATD)," a well-known syndrome of nasal polyposis, bronchial asthma, and aspirin intolerance.

The presence of an allergic disease is not a prerequisite for developing aspirin intolerance. First researchers of this disorder have suggested that it is a nonimmunologic systemic disease. The cause of the disease remains elusive but may be related to a disorder of eicosanoid biosynthesis. Eicosanoids are hormones, but unlike most hormones, are not stored by cells. In response to extracellular stimuli, they are synthesized and released within five to sixty seconds. They are products of arachidonic acid metabolism, which is acted upon by cyclooxygenase and lipoxygenase. The cyclooxygenase pathway involves the creation of prostaglandins and thromboxanes while the lipoxygenase pathway serves to create leukotrienes and hydroxyeicosatetranoic acid. Cyclooxygenase is irreversibly inhibited by aspirin resulting in a shift to the lipoxygenase pathway. These lipoxygenase products promote bronchoconstriction and vasodilation resulting in the increased airway edema and secretions associated with the inflammatory process in ATD.

Traditional medical management of rhinosinusitis in ATD involves systemic and topical decongestants, topical steroids, leukotriene receptor antagonists, antibiotics, and oral steroids. In patients who fail aggressive medical management, endoscopic sinus surgery has been reported to have a favorable long-term effect on asthma. However, some question the role of endoscopic sinus surgery in the management of patients with chronic rhinosinusitis and coexisting asthma.

A team of Wisconsin researchers set out to evaluate the long-term effects of endoscopic sinus surgery on asthma in patients meeting the diagnostic criteria for aspirin triad disease. The authors of "Long-term Asthma Outcomes Following Endoscopic Sinus Surgery in Aspirin Triad Patients," are Todd A. Loehrl MD, Robert J. Toohill MD, Timothy L. Smith, MD MPH, and Robinson M. Ferre, all from the Division of Rhinology and Sinus Surgery, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI. Their findings are being presented at the American Rhinologic Society http:/www.american-rhinologic.org/ meeting being held May 2-6, 2003, at the Gaylord Opryland Hotel, in Nashville, TN.

Methodology: The researchers reviewed the charts of 85 patients diagnosed with ATD who had undergone endoscopic sinus surgery at the Medical College of Wisconsin between 1986 and 1998 All patients had nasal polyps, asthma, and aspirin sensitivity. Asthma was diagnosed by pulmonary medicine; aspirin sensitivity was determined by patient history of increased upper and/or lower airway disease after ingesting aspirin or similar medications. All patients had failed maximal medical management of their rhinosinusitis and were not taking aspirin or non-steroidal anti-inflammatory drugs.

The subjects had elected to undergo endoscopic sinus surgery for their sinonasal disease. Charts were reviewed for presenting symptoms, physical findings, medical management, diagnosis, frequency of asthma attacks, and asthma-related oral steroid use, physician visits, and emergency room visits. In addition a standardized survey was mailed to all patients identified with ATD. Patients were asked to provide subjective information regarding symptom improvement, medication requirements, doctor visits, and emergency room visits as they related to their asthma.

Results: After exclusions, 65 subjects participated in the study. Thirty-four of the 65 (52.3 percent) with ATD who underwent endoscopic sinus surgery responded to the survey. Respondents had a mean follow-up of 10.0 years. Key findings included:

-- Overall, 29 of 31 patients (94 percent) who reported asthma symptoms preoperatively noted long-term post-operative improvement. Furthermore, 21 of these 31 patients (68 percent) reported further improvement of their asthma beyond the first postoperative year.

-- Emergency Room visits for asthma distress decreased in 17 of 18 (94 percent). Inpatient hospitalizations for asthma exacerbations also decreased in the first postoperative year in 10 of 11 (91 percent) patients.

-- Asthma attacks declined in 12 of 27 (41 percent) patients the first year, while 24 of 27 patients (88.9 percent) had a decreased number of asthma attacks in the last 12 months of follow-up. Peak flow rates improved from an average of 60 percent of the predicted value pre-operatively to 86 percent at the time of follow-up.

-- For the 25 patients reporting chronic use of oral steroids pre-operatively, 18 (72 percent) reported decreased usage in the first year. Furthermore, eight of these patients (32 percent) were able to stop using systemic steroids altogether. In the last 12 months of follow-up 22 of 27 patients (81.5 percent) were utilizing less systemic steroids, including 11 patients (44 percent) patients who were able to stop completely. Only two (eight percent) patients required increased dosages of oral steroids in the last 12 months of follow-up.

-- With regard to inhaled steroids, 28 patients required their use preoperatively. At one year after surgery 9 of 28 (32.1 percent) had decreased their dosage of inhaled steroids while one patient was able to stop altogether. However, one patient did require an increased dosage at one year and in the last 12 months of follow-up, 5 of the 28 patients had to increase their inhaled steroid usage.

Conclusions: This study which focuses on a large cohort with ATD over a long follow-up period (mean follow-up = 10.0 years), supports the effectiveness of endoscopic sinus surgery in the treatment of the asthmatic component of the disorder. When all factors are considered, the vast majority of patients reported a decrease in their asthma severity at one year and at a mean follow-up of 10.0 years postoperatively.

This study indicates that endoscopic sinus surgery positively impacts the asthmatic component of ATD. Substantial improvement occurs in the short term and the findings are even more favorable in the long-term. This may result in a reduction of the morbidity of the disease as well as the medication necessary to manage the lower airway disease. It could also be surmised that healthcare costs are reduced given the decreased need for medications, urgent physician visits, emergency room visits, and hospitalizations.