Endoscopic sinus surgery improves aspirin treatment response in aspirin‐exacerbated respiratory disease patients

Abstract

Background Aspirin desensitization and treatment benefits most patients with aspirin‐exacerbated respiratory disease (AERD), although some patients fail therapy. Our objective was to assess whether recent endoscopic sinus surgery (ESS) improved aspirin treatment outcomes in AERD patients who initially failed aspirin therapy. Methods Outcomes of aspirin desensitization and treatment in AERD patients prospectively enrolled were assessed preoperatively and at 4, 12, and 24 weeks after ESS by determining changes in Asthma Control Test (ACT) and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores and respiratory function. Biomarkers, including fractional excretion of nitric oxide (FeNO), spirometry, nasal inspiratory peak flow (NPF), immunoglobulin E (IgE), and eosinophil count, were measured. Results Nineteen patients who benefited (responders) and 21 patients who failed (nonresponders) preoperative aspirin treatment with a distant history of ESS (mean, 48 months) were identified. Nonresponders were more likely to be African American (71%, p < 0.01) and have higher baseline IgE levels (252 kU/L vs 87 kU/L in responders, p < 0.01). 24 of the 40 patients (nine responders and 15 non‐responders) required subsequent ESS and underwent another aspirin desensitization 3‐4 weeks after ESS. All 24 patients tolerated a second round of aspirin desensitization and treatment. The primary aspirin therapy was associated with a significant increase in IgE in nonresponders, but there was no significant increase in IgE after the second aspirin desensitization and treatment. Conclusion Antecedent ESS enhances aspirin treatment responses in AERD patients and may convert patients who failed aspirin treatment before surgery to a more responsive phenotype after ESS. Patients with higher baseline serum IgE levels may benefit from ESS performed shortly before aspirin desensitization and therapy.

Systematic review of outcomes for endoscopic sinus surgery and subsequent aspirin desensitization in aspirin‐exacerbated respiratory disease

“…Shah et al 16 performed a prospective cohort study evaluating 24 patients that previously failed aspirin desensitization. These patients subsequently underwent endoscopic sinus surgery (ESS) and postoperative aspirin desensitization.…”

“…The study by Shah et al, suggests that endoscopic sinus surgery may actually improve responsiveness for aspirin desensitization in those patients that previously failed aspirin desensitization. 16 …”

The role of aspirin desensitization followed by oral aspirin therapy in managing patients with aspirin-exacerbated respiratory disease: A Work Group Report from the Rhinitis, Rhinosinusitis and Ocular Allergy Committee of the American Academy of Allergy, Asthma & Immunology

“…Subsequent observational studies have examined larger cohorts of patients with AERD who were desensitized and maintained on daily aspirin for weeks, months, or years [12][13][14][23][24][25][26][27][28][29][30][31][32][33] (Table II). Patients reported subjective improvement in upper and lower respiratory tract symptoms and objective reductions in daily oral steroid requirements as early as 4 weeks following desensitization while on maintenance therapy.…”

Appropriate extent of surgery for aspirin‐exacerbated respiratory disease

“…It appears that antecedent ESS of total ethmoidectomy with maxillary antrostomy with or without frontal sinusotomy can also help increase tolerance of aspirin desensitization in patients who had previously failed desensitization, and the combination of ESS and desensitization has been noted to decrease overall topical and systemic steroid utilization. 29 , 30 While quantitative olfactory performance as assessed by Sniffin’ Sticks improves in AERD patients following a complete functional ESS (FESS), these patients experience limited olfactory recovery over time relative to aspirin-tolerant patients, and are less likely to become normosmic. 31 …”