I saw a 33 year-old women with a history of mild seasonal AR who's symptoms have become more persistent over the past year. No specific triggers identified. She suffers from sneezing, congestion and anosmia. Symptoms are poorly responsive to Claritin and Fluticasone. She has NO history of asthma, but develops wheezing after she takes Aspirin, NSAIDs and Tylenol. On examination, she has a large nasal polyp in her right nares. I will first attempt to treat her more aggressively with intranasal corticosteroids and sinus rinses, but is this someone who may benefit from aspirin desensitization? Her case is somewhat unusual since she is also Tylenol intolerant AND she does not have underlying asthma.


Thank you for your inquiry.

In brief, the answer to your question is if indeed your patient does have aspirin-exacerbation respiratory disease (AERD) with chronic sinusitis and nasal polyps, aspirin desensitization may be helpful. However, I think that there are several features of her history which leads me to suggest that you pursue the diagnosis further before coming to the conclusion that she suffers from this disorder.

Before I mention these features, however, clearly she could have AERD, and several features are consistent with this condition. For example, the presence of anosmia and persistent nasal congestion. However, there are other elements of her history which are puzzling. These are:

1. The vast majority of patients with AERD have bilateral nasal polyps. The presence of a unilateral nasal polyp should call your attention to other entities. I have copied below an abstract (also contained in the previous entry mentioned above) of a study looking at the entities to be considered when a patient has what is thought to be a unilateral nasal polyp.

2. The history of wheezing with the drugs mentioned is puzzling. Although wheezing to acetaminophen can occur, normally, as you well know, acetaminophen would not produce wheezing in a patient with AERD, and the fact that your patient presents with this history would make me have doubts as to the validity of her observations in this regard.

So I would pursue the diagnosis further. These are the things that I would suggest you do:

A. If only anterior rhinoscopy was used to look for polyps, I would have her examined using fiberoptic or other forms of rhinoscopy that can examine the nasal cavity in its posterior portion to see if indeed she does have bilateral polyps.

B. A CT scan of the sinus, if it has not been done, should be done. Patients with AERD usually have extensive sinusitis involving ethmoids and maxillaries, and this sinusitis is for the most part bilateral.

C. Patients with AERD have hypereosinophilia in nasal tissue and quite often in blood. So I would look for Eosinophils in these locations.

In summary, your patient may indeed have AERD with nasal polyps, and if this is the case, aspirin desensitization could be helpful. However, I would consider pursuing the diagnosis further as mentioned above.

Thank you again for your inquiry and we hope this response is helpful to you.

Am J Otolaryngol. 2008 Jul-Aug;29(4):230-2. Epub 2008 Mar 17.
Unilateral nasal polyposis: clinical presentation and pathology.
Tritt S, McMains KC, Kountakis SE.
Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia, Augusta, GA 30912, USA.
Objectives: The aim of this study is to determine the clinical presentation and pathology of unilateral nasal polyposis (UNP).
Study Design: Retrospective chart review.
Methods: A retrospective analysis was completed on 301 consecutive patients with nasal polyposis that underwent functional endoscopic sinus surgery from 1995 to 2004. Of the charts reviewed, 46 patients were identified with UNP. In this group, there were 28 males and 18 females with a mean age at presentation of 34.85 years. Pathologic diagnosis was not available for 2 patients, so there were 44 UNP patient records for analysis. Presenting symptoms, surgical findings, and pathology were analyzed.
Results: All 44 patients underwent surgical management for their symptoms, and specimens were sent for pathologic evaluation. There were 17 cases of chronic rhinosinusitis, 15 of allergic fungal sinusitis, 7 of inverting papilloma, 2 of squamous cell carcinoma, 1 of esthesioneuroblastoma, 1 of mucocele, and 1 of human papilloma virus polyp-type papilloma. The only presenting symptom that correlated with the presence of inverted papilloma or neoplastic process in our patients with UNP was epistaxis.
Conclusions: Chronic rhinosinusitis, allergic fungal sinusitis, inverting papilloma, and other neoplasms account for most UNP cases and must be considered when a patient presents with symptoms of unilateral polyps. A careful history and endoscopic examination play a key role in identifying possible disease processes and proper management.

Phil Lieberman, M.D.

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