Contemporary management of chronic rhinosinusitis with nasal polyposis in aspirin‐exacerbated respiratory disease: an evidence‐based review with recommendations

Abstract

Background Chronic rhinosinusitis (CRS) in aspirin exacerbated respiratory disease (AERD) represents a recalcitrant form of sinonasal inflammation for which a multidisciplinary consensus on patient management has not been reached. Several medical interventions have been investigated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach for the multidisciplinary management of CRS in AERD. Methods A systematic review of the literature was performed and the guidelines for development of an evidence-based review with recommendations were followed. Study inclusion criteria included: adult population>18 years old; CRS based on published diagnostic criteria and a presumptive diagnosis of AERD. We focused on reporting higher-quality studies (level 2 or higher) when available, but reported lower-quality studies if the topic contained insufficient evidence. Treatment recommendations were based on American Academy of Otolaryngology guidelines, with defined grades of evidence and evaluation of research quality and risk/benefits associated with each treatment. Results This review identified and evaluated the literature on 3 treatment strategies for CRS in AERD: dietary salicylate avoidance, leukotriene modification and desensitization with daily aspirin therapy. Conclusion Based on the available evidence, dietary salicylate avoidance and leukotriene modifying drugs are options following appropriate treatment with nasal corticosteroids and saline irrigation. Desensitization with daily aspirin therapy is recommended following revision ESS.

The Effect of Antileukotrienes on the Results of Postoperative Treatment of Paranasal Sinuses in Patients with Non-Steroidal Anti-Inflammatory Drug-Exacerbated Respiratory Disease

“…Despite the significant importance of disturbances in the metabolism of arachidonic acid leading to the overproduction of proinflammatory CysLTs, drugs blocking receptor or leukotriene C4 synthase (LTC4S) are not recommended [1]. This is in contradiction with reports from the literature [3, 6, 8, 12, 16]. The last update of the ARIA document (Allergic Rhinitis and its Impact on Asthma) from 2016 allows to use antileukotrienes (LTRAs) as a supplement to therapy, especially in patients with asthma, in the case of seasonal allergic rhinitis [22].…”

“…The etiology of the disease has not been explained. It is often associated with disruption of the arachidonic acid metabolic pathway and overproduction of leukotrienes [8, 9]. Feng et al [10] have found that in patients with NSAID-exacerbated respiratory disease (NERD) eosinophils have a greater capacity to produce and secrete prostaglandins D 2 after aspirin stimulation compared to healthy subjects.…”

“…Endoscopic sinus surgery (ESS) in patients with NERD is often extensive and performed repeatedly [9, 17], hence the need to develop the most beneficial postoperative treatment that would allow to avoid reoperation as long as possible. In addition to surgical treatment of patients with hypersensitivity to NSAIDs, it is recommended to use a low-acetylsalicylic acid diet [8, 18], drugs inhibiting cysteinyl leukotriene (CysLT) synthesis (Zileuton) or CysLT receptor blockers (montelukast, zafirlukast), and topical and systemic steroids [8, 19]. Aspirin desensitization is another option [8, 9, 20].…”

“…In addition to surgical treatment of patients with hypersensitivity to NSAIDs, it is recommended to use a low-acetylsalicylic acid diet [8, 18], drugs inhibiting cysteinyl leukotriene (CysLT) synthesis (Zileuton) or CysLT receptor blockers (montelukast, zafirlukast), and topical and systemic steroids [8, 19]. Aspirin desensitization is another option [8, 9, 20]. According to the EPOS 2012 guidelines, in addition to ESS, the treatment of patients with CRSwNP and hypersensitivity to NSAIDs is based on local or systemic steroids.…”

“…Despite the significant importance of disturbances in the metabolism of arachidonic acid leading to the overproduction of proinflammatory CysLTs, drugs blocking receptor or leukotriene C4 synthase (LTC4S) are not recommended [1]. This is in contradiction with reports from the literature [6, 8, 12]. …”