The prevalence of Samter's triad in patients undergoing functional endoscopic sinus surgery

Ear, Nose & Throat Journal, July, 2007 by Ji-Eon Kim, Stilianos E. Kountakis

Abstract

We conducted a retrospective study to determine the prevalence of Samter's triad (nasal polyps, asthma, and aspirin sensitivity) in 208 consecutively presenting patients who had undergone functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis from September 2001 through August 2003. Overall, Samter's triad was found in 10 patients (4.8%); subgroup analyses showed that the prevalence of Samter's triad was 5.9% in adults, 9.4% in patients with nasal polyps alone, 16.9% in patients with asthma alone, and 25.6% among patients with both polyps and asthma. On average, patients with Samter's triad had undergone approximately 10 times as many previous FESS procedures as had the patients without Samter's triad (mean: 5.2 vs. 0.53; p < 0.001). In addition to Samter's triad, four other factors were independently and significantly associated with a higher number of previous FESS procedures: nasal polyps alone, asthma alone, both polyps and asthma, and cystic fibrosis alone. Finally, at 6 months following their most recent surgery, patients with Samter's triad had significantly higher rates of symptom recurrence (nasal obstruction, facial pain, postnasal drip, and anosmia) and a recurrence of nasal polyps.

Introduction

Samter's triad--the combination of nasal polyps, asthma, and aspirin sensitivity--was first described by Samter and Beers in 1968. (1) In affected patients, it is thought that aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit the activity of the enzyme cyclo-oxygenase-1 (COX-1) in the arachidonic acid metabolism pathway, resulting in an increase in the activity of the enzyme 5-1ipoxygenase. The products of the 5-1ipoxygenase pathway include the leukotrienes LTC4, LTD4, and LTE4, which are potent inflammatory mediators that can act to (1) induce mucus secretion, bronchoconstriction of the airway, and edema of the nasal mucosa and (2) attract eosinophils into the airways. Indeed, patients who are aspirin-sensitive have been shown to have higher concentrations of leukotrienes than do nonsensitive patients. (2-4) Understandably, patients with Samter's triad generally tend to have more severe symptoms of nasal polyposis and asthma, as well as rhinosinusitis, than do patients without the triad.

Patients with Samter's triad are frequently treated with functional endoscopic sinus surgery (FESS), but their postoperative course is often complicated by a recurrence of nasal polyps. Not much is known about the prevalence of Samter's triad in the general population of patients undergoing FESS or about the postoperative symptomatic outcome of these patients compared with the outcomes of patients without the triad. The goal of our study was to assess the prevalence of Samter's triad among patients undergoing FESS and to report on their surgical outcomes.

Patients and methods

We conducted a retrospective review of the charts of 208 consecutively presenting patients--107 males and 101 females, aged 2 to 80 years (mean: 33.3 [+ or -] 19.2; median: 33)---who had undergone FESS for chronic rhinosinusitis at the Medical College of Georgia from September 2001 through August 2003. The ratio of whites to blacks was almost 2:1 (62.0 and 34.1%, respectively), and the ratio of adults to children was roughly 3:1 (73.1 and 26%, respectively).

In addition to demographic data, we recorded the number of previous FESS procedures that each patient had undergone and information on each patient's presenting complaints, diagnosis, type of most current surgery, and 6-week and 6-month postoperative complaints to assess the short-term effectiveness of FESS. The presence of Samter's triad was based on information obtained from the history; the presence of nasal polyps was documented by nasal endoscopy.

All patients had been initially treated with medical therapy, which included intranasal steroid sprays, mucolytics, normal saline nasal washes, and antibiotics when indicated. Patients with nasal polyps were also treated with oral steroid tapers as needed, based on disease severity. Patients with objectively documented (by computed tomography and nasal endoscopy) chronic rhinosinusitis were offered FESS if medical management failed to control their symptoms.

The data were analyzed according to standard statistical methods. The Student's t test was used to compare means between subgroups, and the chi-square test was used to analyze variables reported as frequencies. The threshold for statistical significance wasp < 0.05. The study protocol was approved by our institutional review board.

Results

Prevalence of Samter's triad. Ten of the 208 patients (4.8%) exhibited the three elements of Samter's triad (figure 1). Subgroup analyses showed that the prevalence of Samter's triad was relatively high in patients with nasal polyps (9.4%), asthma (16.9%), and both nasal polyps and asthma (25.6%).

Demographic variables. The prevalence of Samter's triad was much higher among adults (9 of 152 [5.9%]) than children (1 of 56 [1.8%]). The mean age of patients with Samter's triad was slightly higher than the mean age of the study population as a whole (37.6 vs. 33.3 years;p = 0.47); while this difference was not statistically significant, it is consistent with the observation that aspirin sensitivity most commonly manifests when patients are in their 30s and 40s2 Patients with Samter's triad were disproportionately female (70% of all cases) and black (50%), but again, neither finding was statistically significant.