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The Asthma and Sinusitis Connection: a common finding

Asthma and Sinusitis: basics

Many patients with chronic sinusitis and severe nasal polyps or recurring nasal polyps also have asthma.  Many of these patients have increased levels of circulating inflammatory mediators, which might be thought of as chemicals or cells that circulate in the blood stream and tissues and stimulate an intense inflammatory reaction.

First, What is Asthma?

I'll borrow from Wikipedia, here, because the links are good.

Asthma is a chronic illness involving the respiratory system in which the airway occasionally constricts, becomes inflamed, and is lined with excessive amounts of mucus, often in response to one or more triggers. These episodes may be triggered by such things as exposure to an environmental stimulant (or allergen), cold air, warm air, moist air, exercise or exertion, or emotional stress. In children, the most common triggers are viral illnesses such as those that cause the common cold.[1] This airway narrowing causes symptoms such as wheezing, shortness of breath, chest tightness, and coughing. The airway constriction responds to bronchodilators. Between episodes, most patients feel well but can have mild symptoms and they may remain short of breath after exercise for longer periods of time than the unaffected individual. The symptoms of asthma, which can range from mild to life threatening, can usually be controlled with a combination of drugs and environmental changes.

Public attention in the developed world has recently focused on asthma because of its rapidly increasing prevalence, affecting up to one in four urban children

Asthma and Sinusitis: The connection is nasal polyps.

A subset of these patients with asthma and polyps will be sensitive to aspirin and other nonsteroidal anti-inflammatory medications such as Motrin, ibuprofen, Anaprox, and Alleve.    There are dozens more anti-inflammatory drugs, most of which will be listed in a separate handouts.

In our clinic, we try to whether a patient has asthma with aspirin sensitivity or asthma without aspirin sensitivity early in the evaluation process, because this factor often substantially affects our treatment recommendations (as well as the outcomes for various possible treatments of nasal polyps).  So, if you're evaluated and our clinics, you may be asked if you had a reaction to aspirin, Motrin, ibuprofen, or other anti-inflammatory drugs.  You may want to consider this before your evaluation are clinic, or before evaluation by any ENT surgeon.  The reaction that is of most interest to us is whether you've ever had an asthma attack or exacerbation of your wheezing within 20 minutes to three hours after taking any of these drugs.  Also, if you had worse nasal congestion, clear runny nose, or watery eyes after taking these drugs, you should alert your caregiver about the possibility of a reaction to aspirin.  This has a good chance of altering your treatment recommendations.

Identifying patients who are sensitive to aspirin and other anti-inflammatory drugs is very important to treat their polyps, but also can be life saving from the perspective of the patient's asthma.  We have seen many patients who have not identified their sensitivity to aspirin and anti-inflammatory drugs and several patients who have had heart attacks or strokes due to severe allergic reactions to aspirin which the patient took because he or she was unaware of their sensitivity to the drug.

Medical treatment of patients with aspirin sensitivity and nasal polyps is often different (at least in some ways) than patients with polyps who do not have sensitivity to these anti-inflammatory drugs.  What are those differences?

1. First, patients with aspirin sensitivity frequently have severe asthma and require multiple medications to control their asthma symptoms.  We find that most of these patients need to be on a long acting steroid inhaler or asteroid inhaler that is combined with a drug to dilate the airwaves (a bronchodilator).
2. Second, patients with aspirin sensitivity may benefit from the addition of a pill named Singulair to improve their asthma.  Singulair is a drug designed to block the inflammatory pathway that is particularly overactive in patients with aspirin sensitive asthma.  Your ENT doctor may discuss these drugs with you if you're not currently taking them and may work with you or your asthma doctor to consider whether these drugs are warranted in your case or whether a trial of these drugs may be warranted.
3. Patients with aspirin and nonsteroidal drug sensitivities may respond to oral prednisone to shrink the polyps in their nose and sinuses.  Unfortunately, the effect is usually short lasting and the polyps will often (but not always) grow back rather quickly after a short burst of oral steroids has been given.  We occasionally see a patient who can take a short course of oral steroids and obtain an improvement for several months.
4. Patients with aspirin sensitivity and nasal polyps frequently have polyps are so large that the nasal steroid spray that they inhale each day only covers a very small amount of the surface and of the polyps.  When polyps are very large and steroid sprays only cover a small were sent into the polyps, the steroid sprays don't work particularly well.  These steroid sprays may be slowing growth the polyps, but the sprays may not be truly shrinking the polyps.  In this situation, we sometimes recommend surgery, but there are several factors that go into this consideration, most of which are brought beyond the scope of this webpage.
5. If there is a clinical concern that a patient might possibly be aspirin sensitive, we will often have them assessed by our allergy colleagues who can perform testing for sensitivity to aspirin or other anti-inflammatory drugs.  Identification of such allergies is critical since patients may benefit from avoiding aspirin and other anti-inflammatory drugs.  In addition, identifying the sensitivity to anti-inflammatory drugs opens another treatment possibility: aspirin desensitization.

6.  Aspirin desensitization can be performed as part of the treatment for triad asthma.  There are several reports out of the Stanford University that have evaluated aspirin desensitization as a treatment option for patients with asthma, aspirin sensitivity, and nasal polyps. ( J Allergy Clin Immunol 98:751-8, 1996).  These studies have shown that a substantial number of patients who undergo aspirin desensitization have less frequent asthma exacerbations and require nasal polyps surgery less frequently.  Our experience is similar to this.  In addition, we have found that many of our patients with nasal polyps have diminished amounts of  thick, yellow, mucinous discharge and lesser amounts of clear, watery rhinorrhea if they are able to undergo the aspirin desensitization.  For more information on aspirin desensitization, follow this link on aspirin desensitization.

Please read the following information or more on Aspirin Sensitive Respiratory disease (also known as triad asthma).
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Triad Asthma

What is triad asthma?
Triad asthma is a clinical syndrome defined by three findings: asthma, aspirin sensitivity, and nasal polyposis.  Triad asthma was discovered in 1922 and has gone by several names since then, including aspirin hypersensitivity triad, Samter’s triad, and Fernand Widal Triad.  Today it is commonly called triad asthma, Samter’s triad, or Aspirin-related Respiratory disease. 

Who gets triad asthma?
            Triad asthma most commonly starts in patients over the age of twenty, but can occur in younger adults or children.  In the adult clinics at the University of Michigan, most patients report onset of symptoms between the ages of 20-40.

So what?  Why should someone worry about triad asthma?
If you are reading this brochure, chances are that you have already been substantially bothered by your triad asthma, perhaps by the nasal, sinus or breathing problems associated with this disease.  To be certain, the most critical reason a patient needs to be aware of this diagnosis is because patients with triad asthma may have very sudden, very severe asthma attacks which can be triggered by foods or medications.  Patients must be aware of their sensitivities to drugs and to some foods and should take precautions to avoid them.

How can someone tell if they have triad asthma?  What are the symptoms?
            Your doctor can help you determine if you have triad asthma.  The diagnosis is sometimes difficult because every patient does not have all three parts of the triad.  Patients may develop the three symptoms (asthma, polyps, and aspirin sensitivity) over a period of a few months or decades.
Patients with triad asthma commonly report the sudden onset of profuse clear rhinorrhea (runny nose) and nasal congestion which makes it difficult for them to breathe through their nose.  In many cases, the runny nose is so incredibly severe that it becomes socially quite embarrassing for patients.  After a while, the rhinorrhea becomes less severe, but patients may have persistent congestion and most complain that their sense of smell is dramatically reduced.
Within days or sometimes over a period of years, patients with triad asthma may develop the main “triad” problems: asthma, nasal polyps and aspirin sensitivity.  In many patients the asthma comes first, but in others the nasal polyps develop prior to the asthma.  Patients who develop asthma may first experience a chronic cough, which usually progresses to coughing and wheezing.  Patients may have episodes of severe asthma attacks that may be triggered by environmental allergens, irritants (like cold air), exercise or aspirin (also abbreviated as ASA for acetylsalicylic acid).  In addition, patients with triad asthma may have asthma attacks that are precipitated by NSAIDS-Nonsteroidal Anti-Inflammatory Drugs-such as Motrin, Ibuprofen, Advil, Anaprox, Daypro, etc.  Since aspirin is commonly found in many over the counter medications (such as cold medications), and since there are more than 13 different NSAIDs, patients must be very vigilant about avoiding these drugs.
For many patients, nasal polyps may be present at the time of their diagnosis of triad asthma, but for others the polyps may have been there for years, or may develop many years later.  Nasal polyps are round, yellow-tan, glistening masses that arise from the tissue (called mucosa) in the nose.  As the polyps grow, patients may experience worsening nasal congestion and decreasing sense of smell.  As the congestion worsens, patients often find they may become “mouth breathers,” may start to snore at night, and may get more pressure sensation over the nose and sinuses from the polyps. 

     Because the polyps block airflow to the olfactory area (where the nerve ending is that detects aromas), patients lose their sense of smell.  Unfortunately, this also greatly affects patient’s sense of taste as well, because most of what people taste is really a smell.  The tongue can only really taste four things: Bitter, sweet, sour, and salty.  All other tastes are really smells.  So the taste of mocha coffee is the bitter coffee taste, perhaps a sweet sugar taste, and a lot of the smell of the chocolate.  Many patients are quite bothered by their poor sense of taste.
For many patients their sense of smell improves substantially if they are given steroid medications by mouth (for asthma or other reasons), but the improvement is usually short-lived.  When the steroids are stopped the hyposmia (decreased smell) returns in most cases. 
The final part of triad asthma is aspirin sensitivity.  Patients sensitive to aspirin will typically have an acute attack of asthma (or bronchospasm) that starts 20 minutes to 2 hours after they swallow aspirin.  The first symptom is may be a bad “runny nose,” nasal congestion, watery nose, watery eyes, and then an asthma attack which can be severe enough to require hospitalization.  Some patients can have abdominal complaints such as nausea, vomiting, cramping, pain or diarrhea.  These symptoms can vary over time.
Unfortunately, any of the NSAIDs may cause this same sensitivity reaction.  Although this reaction to aspirin and NSAIDs is, scientifically speaking, not a “true allergy,” patients are advised to consider this as a drug allergy which should be reported to all healthcare providers and pharmacists.  Patients must avoid these medications.  Tylenol can be taken in usual doses, but should not be taken in amounts greater than 1000 mg at a time, as long as the patient has never had a reaction to Tylenol (which is uncommon).

What if someone has asthma and nasal polyps?  What are the chances they have or will get triad asthma?
            Many patients that have asthma also have significant nasal allergies.  Allergies that affect the nose will cause symptoms such as sneezing, itchy nose and eyes, rhinitis (runny nose), and nasal congestion.  Such things as cats, dust, molds, pollens, trees, and grasses commonly cause nasal allergy, also known as allergic rhinitis.  Most people with allergic rhinitis date their problems to childhood.  Anyone with allergic rhinitis can get nasal polyps from their chronic allergies.  Most patients with allergic polyps have had the nasal allergies since they were children, while the triad asthma patients with asthma and polyps will typically date their problems to early adulthood rather than childhood
For the average patient with nasal polyps and asthma, the chance of developing aspirin sensitivity is about 40-50% and can occur many years after the other symptoms.  So, it is advisable for patients with asthma and problematic nasal polyps to avoid aspirin and NSAIDs.  Speak to your doctor about this if you have questions.

What can be done to help my nose and sinuses if I have triad asthma?
            Patients with triad asthma will have inflammation, congestion, and poorly functioning cilia in the nose.  Since cilia clear the mucus from the nose, triad asthma patients usually complain of thick mucus that is difficult to clean from the nose.  If the mucus is not cleared it will often become infected, turn yellow green, and may cause an exacerbation of patient’s asthma.   To help clean the thick mucus and prevent infections we recommend that patients do the following:

• Use saline sprays (such as Ocean Spray, Salinex, or Ayre) on a frequent basis.
• Use salt-water irrigations on a daily basis---once or twice a day as needed.  We recommend using a nasal irrigation system such as the Neilmed Sinus Rinse bottle which is available at many pharmacies or over the Internet.
• Use a prescription steroid nasal spray to reduce inflammation and slow the growth of polyps.

Occasionally, patients may be prescribed a short course of oral steroids, which will usually reduce the size of the polyps.  However, steroids alone are only a temporizing measure, because the polyps grow back shortly after the steroids are stopped.

What about my asthma?  Who should be managing this problem?
Most primary doctors are aware of triad asthma and most are very comfortable managing asthma treatment for triad patients.  Unfortunately, many patients with triad asthma may have wheezing that is very difficult to control.  If you and your primary physician feel that your asthma is particularly problematic or concerning, you may want to see a specialist; either an allergist or pulmonologist, who has particular expertise in managing patients with asthma.  There are a number of medications that are very helpful.  In addition, there is a new class of medications (known as leukotriene inhibitors, such as Singulair or Zyflo) which are available in pill form and may benefit some patients.  Patients that have been taking long-term steroid medications by mouth or injection should consider seeing a specialist and/or discussing this with their primary doctors.

When is surgery indicated for someone with triad asthma?
            The decision to proceed with surgery is very dependent on the patient’s symptoms and the impact on the patient’s lifestyle.  Therefore, the threshold where patients elect to perform surgery is quite variable.  However, there are some general guidelines.  First, the presence of nasal polyps alone is not necessarily an indication of surgery, since patients with this disease will almost always have some degree on nasal polyps.  Common factors that your physician may consider in discussing surgery may be:

• The degree of nasal obstruction the patient has and how bothered the patient is by the symptoms. (i.e., are they snoring, not sleeping or continuously mouth breathing?)
• The frequency and severity of symptoms of sinusitis that a patient may have.  Sinus infections in patients with triad asthma are often difficult to clear because the sinuses do not drain well and the infected cavities become quickly reinfected once antibiotics are stopped.
• Whether the patient’s sinus problems and sinusitis is causing exacerbation of their asthma.  Patients that are requiring substantial amounts of oral steroid medications may be able to reduce their asthma medication requirements with successful surgery. 
• Chronic headaches or other signs of potential complications due to polyps and sinus disease.  Your sinus specialist is qualified to assess these more unusual reasons for surgery.

When is a CT scan or MRI of the sinuses needed?
            An imaging study of the sinuses may be needed to assess the degree of sinus or nasal polyp disease in a patient with triad asthma.  MRI scans are rarely used for evaluating polyps or sinus disease.  Computerized Tomography (CT) scans are usually the preferred study.  Your primary care doctor may order this prior to your evaluation, or your sinus specialist may order one.  A CT scan takes about 10-20 minutes and is usually quite easy for patients. However, if you have any claustrophobia or severe neck arthritis, let your physician and the radiologist know.  Usually, there is no contrast or injection given for a sinus CT scan.

What about the aspirin sensitivity and the NSAIDs?
            All patients with triad asthma or patients that are likely to develop triad asthma should avoid medications that contain aspirin.  This would require that patients look at over-the-counter medications very carefully since many of them contain large or small amounts of aspirin (acetylsalicylic acid).  There are also a large number of NSAIDs that patients should avoid.  Some of the more common NSAIDs are llisted below by their generic name followed by their trade name.

• Bromfenac = Duract                                             
• Ketorolac = Toradol
  Diclofenac = Volteren, Cataflam
• Meclofenamate = Meclomen
  Diflunisal = Dolobid                             
•  Mefenamic acid = Ponstel   
  Etodolac = Lodine    
• Meloxican = Mobic
  Fenoprofen = Nalfon                                
• Nabumetone = Relafen
  Flurbiprofen = Anasaid
• Naproxen = Aleve, Anaprox, Naprelan,   
  Flurbiprofen Sodium = Ocufen              
• Napron X, Naprosyn
  Ibuprofen = Advil, Motrin IB, Nuprin,    
• Oxaprozin = Daypro
  Provel, Rufen          
•  Piroxicam = Feldene
  Indomethacin = Indocin                
• Sulindac = Clinoril
  Ketoprofen = Actron, Orudis, Oruvail  
• Tolmetin = Tolectin
  

2.  Is there an infection as well as polyps, or just polyps and thick mucus?

Many patients with severe nasal polyps produce a thick, yellow, rubbery mucus that is allergic to send commonly referred to as "allergic mucin".  Patients who have experienced allergic mucin describe it as almost as rubber cement in its consistency.

When we evaluate patients at the Michigan sinus Center, we try to determine whether a patient has this allergic mucin (which is quite unusual in the typical population) or whether the patient has yellow-green nasal discharge that is more like the mucous we all get when we experience a particularly bad cold or a routine type of sinus infection.  So, we ask patients if they have the yellow, rubber cement type of allergic mucin or the more routine infected type of mucus that one might imagine in a preschooler with a "snotty nose".

 Although this distinction is a bit graphic, we find that patients are easily able to identify which type of discharge they are experiencing.  And it's important from a diagnostic and treatment standpoint to try to understand which type of discharge a patient with polyps (or without polyps) is experiencing.  We find that patient with polyps and the thick, rubbery, allergic mucin respond incredibly well to a burst and taper of oral steroids (such as prednisone).  The polyps shrink, the amount of yellow, rubbery, allergic mucin diminishes dramatically, and the patients often have substantial improvement.  When patients have polyps and allergic mucin (but no "snotty nosed mucus"), the improvement with oral steroids is typically much much greater than the patient would experience with antibiotics alone.  Patients typically say they get dramatic responses with oral prednisone and about 10% of that type of dramatic response when they take antibiotics alone.  Of course, when patient take antibiotics and steroids together, it's difficult to ascertain which drug is providing the greatest amount of relief, but our experience has been that patients with allergic mucin as the primary nasal discharge reap most of the benefits from prednisone and minimal benefits for mathematics.

 Patients with polyps and allergic mucin do occasionally get a bacterial infections and then complain of having both types of nasal discharge..  These patients often times have a dramatic exacerbation of their asthma, sometimes develop a very productive cough, and worse wheezing.  When a patient with allergic mucin also develops on infectious type of nasal discharge, the patient often develops a very dramatic increase in an amount of coughed up secretions, coughing, and sometimes wheezing for asthma attacks.  These patients should of course be evaluated by a doctor who can address their asthma exacerbation.  From a nasal standpoint, these patients often benefit from a burst of prednisone and a course of antibiotics.  The choice of antibiotics is a complicated decision, and sometimes either simple, inexpensive, first-line antibiotics are used, but sometimes more broad-spectrum antibiotics are necessary.

We think it's important to note that patients with severe polyps (especially those with asthma and aspirin sensitivity)  often have CT scans that show the sinuses and much of the nasal cavity to be completely full of polyps and thick secretions.  When we operate on these patients, we almost never find signs of a bacterial infection, but typically only find thick, rubbery secretions.  When we call for the secretions, they rarely grow out bacteria.  In fact, and it appears that the secretions are probably full of such toxic chemicals that bacterial infections do not typically take hold in these sinuses.  This confirms our clinical impression that antibiotics are far less useful in patients with nasal polyps and allergic mucin, and that oral prednisone is much more effective.