Clinical Characteristics of Patients with Chronic Rhinosinusitis with Nasal Polyps, Asthma, and Aspirin-Exacerbated Respiratory Disease

Abstract

Background: Aspirin-exacerbated respiratory disease (AERD) comprises the triad of chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, and intolerance to inhibitors of the cyclooxygenase-1 (COX-1) enzyme. The prevalence of AERD remains unclear, and few studies have compared the clinical characteristics of patients with AERD to those with CRSwNP alone, asthma alone, or both CRSwNP and asthma.

Objective: To determine the prevalence of AERD within a tertiary care setting, and to identify unique clinical features that could distinguish these patients from those with both CRSwNP and asthma or with CRSwNP alone.

Methods: Electronic medical records of patients at Northwestern in Chicago, Illinois, were searched by computer algorithm and then manual chart review to identify 459 patients with CRSwNP alone, 412 with both CRSwNP and asthma, 171 with AERD, and 300 with asthma only. Demographic and clinical features including sex, atopy, and sinus disease severity were characterized.

Results: The prevalence of AERD among patients with CRSwNP was 16%. Patients with AERD had undergone 2-fold more sinus surgeries (P < .001) and were significantly younger at the time of their first surgery (40 ± 13 years) than were patients with CRSwNP (43 ± 14 years; P < .05). Atopy was significantly more prevalent in patients with AERD (84%) or asthma (85%) than in patients with CRSwNP (66%, P < .05). More patients with AERD (13%) had corticosteroid-dependent disease than patients with both CRSwNP and asthma (4%, P < .01) or asthma (1%, P < .001).

Conclusions: AERD is common among patients with CRSwNP; even though patients with AERD have CRSwNP and asthma, the clinical course of their disease is not the same as of patients who have CRSwNP and asthma but are tolerant to COX-1 inhibitors.

Keywords: AERD; Asthma; CRS; CRSwNP; Samter's disease; Sinus.

Figure 1

Algorithm for identifying study cohorts.

Figure 2. Frequency of women and atopy in each group

Significantly fewer women had CRSwNP than CRSwNP+Asthma, AERD, or asthma alone (A). While the majority of all patients examined had physician-diagnosed allergic rhinitis, significantly fewer CRSwNP patients had allergic rhinitis than CRSwNP+Asthma, AERD, or asthma alone (B). Columns represent the number of patients in each group with the values over each column indicating the number of patients who were female (A) or who had physician diagnosed allergic rhinitis (B). Statistical significance was determined by Chi-square test with *p<0.05, **p<0.01, and ***p<0.001.

Figure 3. Sinus disease severity and dependence on oral corticosteroids

AERD patients, on average, had significantly more severe sinus disease (A), underwent more sinus surgeries (B), and were more likely to have oral corticosteroid dependent disease (C) than patients with CRSwNP or CRSwNP+Asthma. The number above each column indicates how many patients had oral corticosteroid dependent disease in each condition (C). Statistical significance was determined by Kruskal-Wallis test with Dunn’s correction (A and B) or by Chi-square test (C) with ** p<0.01 and ***p<0.001.

Figure 4. Pre-operative medication use

When compared to patients with CRSwNP or with CRSwNP+Asthma, AERD patients were significantly more likely to be prescribed oral corticosteroids within 2 weeks of sinus surgery (A). There was no difference in prescribed leukotriene antagonists (B), intranasal corticosteroids (C), and inhaled corticosteroids (D) within 2 weeks of sinus surgery between patients with AERD and CRSwNP+Asthma. The number over each column represents how many patients were taking the medication. Statistical significance was determined by Chi-square test with ***p<0.001.