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Triad Asthma: Special Treatment Considerations

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.

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
  

Aspirin Desensitization

Aspirin Desensitization is a valuable tool for patients with aspirin Sensitivity. It is most useful for patients who are dependent on Oral Steroids (prednisone) for most or all of the year in order to keep asthma symptoms under control or to keep the nasal symptoms from being absolutely intolerable. Patients with Triad Asthma don't usually get complete relief from all nasal sysmptoms. Patients who have minor symptoms off oral steroids may not find it worthwhile to undergo aspirin desensitization, but patients with singificant symptoms off oral steroids, or symptoms despite oral steroids, may want to consider aspirin desensitization.

Aspirin desensitization is not performed at many allergy or ENT practices. Some of the more experienced sites in the USA are the Scripps Clinic, the University of Michigan, and other sites that have allergists who have trained at the Scripps clinic.

Usually Desensitization is done by allergists. It is a fairly intense protocol, and can be dangerous, especially if the desensitization is performed by a physician who has not had formal training or one that has not had substantial experience. Don't consider getting aspirin desensitization by someone who has "done a couple" of them. See a specialist with signficant experience.

Special consideration # 2

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.