Aspirin-exacerbated Respiratory Disease: A Surgeon's Perspective

Educational Objectives

The goal of this program is to improve management of aspirin-exacerbated respiratory disease (AERD). After hearing and assimilating this program, the clinicians will be better able to:

1. Cite evidence comparing computed tomography scores and patient-reported outcome measures in patients with and without AERD.
2. Compare revision rates in patients with and without AERD.

Summary

Chronic rhinosinusitis (CRS) in aspirin-exacerbated respiratory disease (AERD): severity of nasal polyps is similar in patients with and without AERD; computed tomography (CT) scores and patient-reported outcome measures (PROM) for quality of life and endoscopy are all very similar; according to DelGaudio et al (2019), polyps in AERD tend to be localized near the olfactory cleft; depending upon the population, many appear to have atopic disease

Olfaction: studies have shown that patients with AERD have poorer objective orthonasal olfaction than other CRS nasal polyp phenotypes; most patients with AERD have olfactory dysfunction

Sinus surgery: according to a meta-analysis from the speaker’s group, AERD is not a negative predictor for quality of life improvement after sinus surgery; Smith et al (2019) examined 10-yr outcomes to assess recurrence rates; patients with polyps and CRS without polyps have similar improvements in PROM and health utility; an article from an allergist’s perspective in the New England Journal of Medicine recommended aspirin desensitization be performed shortly after sinus surgery; although the goal is to avoid further surgery, repeat polypectomies are common; current treatment focuses on nasal polyp debulking and surgery for sinus ventilation; speaker stresses the importance of facilitating delivery of topical medications and removing the polyps

2010 study: a Canadian study reported a 10-yr series of patients with primary polyp; patients with AERD had a 90% nasal polyp recurrence rate at 5 yr; recurrence rates in patients with aspirin-tolerant asthma was associated with ≈50% of that rate; patients with a favorable phenotype had a 16% recurrence rate; with recurrence at 5 yr, only ≈33% of the AERD group had surgery and ≈50% in the aspirin-tolerant asthma group had surgery; revision rate in patients with a favorable phenotype was ≈15% at 10 yr; revision rate in patients with AERD increased to 89% at 10 yr and ≈50% of that rate in the aspirin-tolerant asthma group; the rate was ≈15% at 10 yr for patients with favorable phenotype; speaker considers polypectomy inferior to comprehensive (“full-house”) functional endoscopic sinus surgery (FESS) or endoscopic modified Lothrop procedure for AERD and is palliative

Polyp recurrence: a study from the speaker’s group on patients with polyps, ≈25% of whom had AERD, found ≈40% had recurrent polyps by 18 mo; overall revision rates after endoscopy are ≈25% at 10 yr; DeConde et al (2017) reported patients with AERD had a 36% revision rate at 10 yr; speaker observed revision surgery is associated with poorer quality endoscopy; Calus et al (2019) found that 90% of patients with AERD had recurrence of nasal polyps at 12 yr with a revision rate of 60%; ≈21% of patients have no recurrence, ≈40% have recurrence but do not need revision, and ≈36% require revision; at 12-yr follow-up, 95% of patients would want to have the surgery again

Delivery of topical therapy: the frontal recess is the most likely site of recurrence; delivering topical therapies to the precise anatomic site requires the appropriate surgical state, the appropriate delivery device and volume, and patient position; the active agent for most patients is a steroid; a study by Harvey et al (2018) assessed mometasone (Nasonex) rinses in patients with or without nasal polyps and steroids; at 1 yr, nasal blockage, endoscopy, and postoperative radiology scores were significantly better with use of the rinse in large volume compared with the spray

Extent of surgery and polyp recurrence: Bassiouni et al (2013) reported with full-house FESS at 1 yr the chance of nasal polyp recurrence was 22%; risk factors include asthma and AERD; revision surgery is ≈37%; 18% recurrence rate if patients underwent a Lothrop procedure; however, the Lothrop procedure does not add any benefit for 90% of patients with polyps; revision rates are decreasing because of changes in surgical philosophy and topical treatments; younger age is a risk factor for revision surgery; influenced by factors such as comorbidities and patient preference; in Dr. Harvey’s study, which included a large number of patients with AERD, patients with olfaction issues preoperatively had no issues postoperatively after the Lothrop procedure and steroid rinses; a study by the speaker’s group found patients with excellent postoperative compliance had the best control of CRS at 1 yr; less compliant patients had poorer control; AERD is the highest risk factor for poor postoperative control

Aspirin desensitization: a study by Dr. Bosso (Naples et al [2020]), showed that in patients with AERD who have surgery, Sino-Nasal Outcomes Test 22-item survey (SNOT-22) decreased; at 30 mo, there was a 9% revision rate with good quality of life; 21% had trouble maintaining desensitization

Biologic agents: with dupilumab, SNOT-22 outcomes go down nearly 20 points; patients with AERD improve by a mean of ≈2 points; for nasal polyp responders, over one-third of patients had no response or got worse with their nasal polyp grade; some improved by 1 point, and just over one-half improved by ≥2 points; in terms of olfaction response rate, ≈75% overall were anosmic; after dupilumab, ≈25% remain anosmic; two-thirds of the group shifted categories, usually into a hyposmia category (not normosmia)

Multiple endotypes and variable response: the speaker’s group found very few patients with polyps had abnormally elevated IL-4 levels, 60% had elevated IL-13, 60% had elevated IL-5, and IgE was less often elevated; IL-5 may be a marker for responders; in a study by Turner et al (2018), patients with AERD had greater IL-5 and IL-13 levels, which may indicate that mepolizumab or dupilumab is more frequently indicated in these patients

Readings

Bassiouni A, Wormald PJ. Role of frontal sinus surgery in nasal polyp recurrence. Laryngoscope. 2013 Jan; 123(1):36-41; Calus L, Bruaene NV, Bosteels C, et al. Twelve-year follow-up study after endoscopic sinus surgery in patients with chronic rhinosinusitis with nasal polyposis. Clin Transl Allergy. 2019 Jun 14; 9:30; DeConde AS, Mace JC, Levy JM, et al. Prevalence of polyp recurrence after endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis. Laryngoscope. 2017 Mar; 127(3): 550–555; DelGaudio JM, Levy JM, Wise SK. Central compartment involvement in aspirin-exacerbated respiratory disease: the role of allergy and previous sinus surgery. Int Forum Allergy Rhinol. 2019 Sep; 9(9): 1017–1022; Harvey RJ, Snidvongs K, Kalish LH, et al. Corticosteroid nasal irrigations are more effective than simple sprays in a randomized double-blinded placebo-controlled trial for chronic rhinosinusitis after sinus surgery. Int Forum Allergy Rhinol. 2018 Apr; 8(4):461-470; Hanna E, Alexiou M, Morgan J, et al. Intensive chemoradiotherapy as a primary treatment for organ preservation in patients with advanced cancer of the head and neck efficacy, toxic effects, and limitations. Arch Otolaryngol Head Neck Surg. 2004;130(7):861-7; Naples JG, Corr A, Tripathi S, et al. Endoscopic sinus surgery and aspirin desensitization improve otologic-specific SNOT-22 scores. World J Otorhinolaryngol Head Neck Surg. 2020 Oct 17;6(4):248-254; Smith TL, Schlosser RJ, Mace JC, et al. Long-term outcomes of endoscopic sinus surgery in the management of adult chronic rhinosinusitis. Int Forum Allergy Rhinol. 2019 Aug; 9(8): 831–841; Spielman DB, Overdeves J, Gudis DA, et al. Olfactory outcomes in the management of aspirin exacerbated respiratory disease related chronic rhinosinusitis. World Journal of Otorhinolaryngology - Head and Neck Surgery. 2020 December; 6(4): Pages 207-213; Ta V, White AA. Survey-defined patient experiences with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol Pract. 2015 Sep-Oct; 3(5):711-8; Turner JH, Li P, Chandra RK. Mucus Th2 biomarkers predict chronic rhinosinusitis disease severity and prior surgical intervention. Int Forum Allergy Rhinol. 2018 Oct; 8(10): 1175–1183; Whitcroft KL, Cuevas M, Haehner A, et al. Patterns of olfactory impairment reflect underlying disease etiology. Laryngoscope. 2017 Feb;127(2):291-295.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Schlosser is a consultant for XHANCE. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Schlosser was recorded virtually at the 11th Annual Cherry Blossom Conference Otolaryngology Update, held March 5-7, 2021, and presented by the George Washington University School of Medicine and Health Sciences. For information on future CME activities from this presenter, please visit https://cine-med.com/cbo. Audio Digest thanks the speakers and meeting presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT550301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.