Aspirin-sensitive
rhinosinusitis is a non-allergic, non-infectious perennial eosinophilic
rhinitis starting in middle age and rarely seen in children. It may also been seen in atopic patients who have developed a mixed type
rhinitis with recurrent airway
infections. There is an intolerance to
aspirin and most other
NSAID. An intolerance to
tartrazine,
food additives, alcohol,
narcotics and local anaesthetics can follow. Most
aspirin-sensitive patients develop
nasal polyps. Untreated, it can lead to
asthma. The frequency of
aspirin intolerance is 6.18% in patients with perennial
rhinitis and 14.68% in patients with
nasal polyps. Immunologic studies of the blood and the
nasal polyps show a hyperreactive immune system with an activation of the eosinophil granulocytes due to a TH1-lymphocyte-activation. In atopic subjects with a mixed type
rhinitis, we found a TH2- and B-lymphocyte-activation as well. Inhibition of eosinophil apoptosis might be a second remarkable change in the immune system of
aspirin-sensitive patients. A key pathogenic event for
aspirin sensitivity is the change of the
leukotriene pathway for
arachidonic acid metabolism releasing high amounts of
leukotrienes LTC4,
LTD4 and
LTE4, effective
chemoattractants and activators of inflammatory cells. For the diagnosis of
aspirin intolerance, nasal, bronchial and oral challenge are available. The sensitivity of nasal challenge with
lysine-aspirin for the diagnosis of
aspirin-sensitive
rhinitis is 0.93, the specificity 0.97. It is the safest test in
aspirin-sensitive asthmatics causing bronchial side effects only in 0.45%.
Therapy of
aspirin-sensitive
rhinosinusitis includes avoidance of
aspirin and
NSAID. A general down regulation of the immune response with glucocorticosteroids is an effective means. We prefer a maintenance dose of budesonid 400 micrograms a day. Systemic
steroids for a reversibility test or in exacerbation due to
viral infection are given in a dose of 50 mg a day for one week. If
steroids don't work well enough, we combine them with
aspirin desensitizations at a maintenance dose of 500 mg a day. Gastrointestinal side effects occur in 20% of the patients with a dose of 500 mg
aspirin a day, in 46% with a mean dose of 1300 mg a day. The combined treatment of topical nasal
steroids and
aspirin-desensitization is effective in 65% of the patients with improvement in the symptoms of hyper-secretion, irritation and blockage, while 73% show improvement of
polyps,
hyposmia and
anosmia. Endonasal endoscopic surgery of the ethmoids, turbinectoms and septoplasty should be done if necessary, especially in cases where
conservative treatment fails. After surgery a further antiinflammatory treatment is absolutely necessary otherwise
polyps reoccur in 90% of the cases after weeks or months. Unfortunately there is so far no curative treatment. New drugs like
cytokine or
leukotriene receptor antagonists give hope for better results in treatment of
aspirin intolerance in the future.