Outcomes after complete endoscopic sinus surgery and aspirin desensitization in aspirin‐exacerbated respiratory disease

Background Surgical treatment of chronic rhinosinusitis with nasal polyposis (CRSwNP) has evolved over the last decade as rhinologists have increasingly used topical steroid therapies and altered surgical techniques. It is important to understand the changes in success rates of surgery and frequency of revision endoscopic sinus surgery (ESS) in CRSwNP. The aim of this study was to retrospectively review the revision surgical rate of CRSwNP patients by evaluating outcomes in a cohort from the Medical University of South Carolina (MUSC). Methods Retrospective review of CRSwNP patients operated upon at the MUSC between 2002 and 2019 by a single surgeon was performed. Assessed factors included demographics, comorbidities, CRSwNP subtype, extent of surgery, and steroid rinse compliance. Logistic regression was performed to identify factors associated with revision surgery. Results Among 338 patients with at least 6 months of follow‐up, 24.9% had revision surgery, with a mean follow‐up of 52.6 months. In patients with any person‐time measure, the revision rate was 5.58 per 100 person‐years. Independent risk factors associated with increased odds ratio (OR) for revision surgery were: younger age (OR, 1.1); prior surgery (OR, 3.3); longer follow‐up (OR, 1.1); and surgery before 2009 (OR, 2.4) (p < 0.05 for all). Conclusion The revision surgery rate for CRSwNP was 24.9% among those with at least 6 months of follow‐up. Risk factors for higher revision rates included younger age, previous surgery, longer follow‐up, and surgery at the MUSC prior to 2009. As we enter an era of personalized medicine, it is important to consider patient‐ and surgeon‐specific factors, which impact revision surgery rates.

Section: Discussionsupporting

confidence: 55%

Factors impacting revision surgery in patients with chronic rhinosinusitis with nasal polyposis

Loftus

Soler

Desiato

et al. 2020

“…Therefore, patients are able to safely undergo surgery after AsaD if needed, resume their aspirin doses following surgery, and avoid the need for a formal repeat desensitization. This benefit, along with the advantages of AsaD identified in the present study and many others, argue in favor of AsaD as the standard of care in appropriate AERD patients. Yet this treatment option remains relatively poorly accessible even in the United States.…”

Section: Discussionsupporting

confidence: 62%

“…Regarding timing of surgical intervention, for those patients who underwent AsaD as well as surgery during the 6‐year period, surgery occurred a median of 61 days before AsaD. Although formal recommendations for timing of AsaD after surgery are not published, clinically, AsaD is often performed within 1 to 3 months after surgery, coinciding with the timeframe when the polyp burden is relatively low but after healing has taken place . For patients who underwent multiple surgeries, the time interval between surgeries was approximately 2.5 times greater in patients who had undergone AsaD, demonstrating a potential protective effect of desensitization in these patients.…”

Section: Discussionmentioning

confidence: 99%

Treatment practices for aspirin‐exacerbated respiratory disease: analysis of a national insurance claims database

Roland

Nagy

Wang

et al. 2019

Background Aspirin‐exacerbated respiratory disease (AERD) is the triad of asthma, nasal polyposis, and sensitivity to cyclooxygenase‐1 inhibitors. Treatment options include medical management, surgical intervention, and aspirin desensitization (AsaD). Methods AERD patients were identified using the MarketScan Database from 2009 to 2015. Patients were included using International Classification of Diseases, 9th edition (ICD‐9) codes for asthma, nasal polyposis, and drug allergy. Treatments were determined by Current Procedural Terminology (CPT) codes for drug desensitization and endonasal procedures. Geographic trends and timing of interventions between those exposed and not exposed to desensitization were explored. Results A total of 5628 patients met inclusion criteria for AERD, with mean age 46 years, 60% female; 395 (7%) underwent AsaD and 2171 (39%) underwent sinus surgery. Among patients who were desensitized, 229 (58%) underwent surgery, of whom 201 (88%) had surgery prior to AsaD (median [quartile 1, quartile 3]; 61 days [30, 208] prior to desensitization). For patients undergoing surgery following AsaD (n = 46), surgery was performed a median of 302 (163, 758) days after AsaD. Nineteen patients had multiple surgeries post‐AsaD with median time between surgeries being 734 days (312, 1484); 261 patients were not desensitized to aspirin but did undergo multiple surgeries, with the median of the median time between surgeries being 287 days (15, 617), which is shorter than for patients post‐AsaD (p < 0.001). Conclusion A very small percentage of AERD patients undergo AsaD. Patients who had AsaD underwent surgery approximately 2 months prior to AsaD. Patients who underwent AsaD experienced an increased time between surgeries compared to patients who did not undergo AsaD.

“…6 Aspirin desensitization followed by daily maintenance appears to be safe and effective in improving airway disease and quality of life even after 10 or more years of continuous use. 7 Although ESS enhances aspirin treatment response in patients with AERD when performed 3-6 weeks before initiation of aspirin desensitization and treatment, 8 there is insufficient research on aspirin desensitization outcomes with and without antecedent ESS. In addition, aspirin seems to benefit some patients, even if surgery timing was not accounted for or if ESS was performed >12 months before start of aspirin treatment.…”

mentioning

confidence: 99%

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

Shah

Abuzeid

Ponduri

et al. 2019

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.