Rhinology Abstracts

Otolaryngology

Review of postoperative care for Samter's triad patients undergoing endoscopic sinus surgery: A double-blinded, randomized controlled trial

Rotenberg BW, Zhang I, Arra I, and Payton K. Laryngoscope 121: 2702–2705, 2011

Chronic rhinosinusitis with polyposis (CRSwP) is a commonly encountered disease entity. In the subpopulation of Samter's triad, consisting of nasal polyposis, aspirin allergy and asthma, patients are particularly refractory to medical and surgical therapy. Preoperatively, oral and nasal steroids as well as saline irrigations are the mainstay of treatment. Those who fail medical therapy are referred for endoscopic sinus surgery (ESS), with the goal being symptom control and not necessarily disease resolution or cure.

This particular study assessed the postoperative medical regimen in the Samter's triad subpopulation. In a prospective, double-blinded, randomized, controlled trial, three medication regimens were tested. Group A consisted of saline irrigation alone. Group B consisted of saline irrigation plus separate budenoside nasal spray. Group C consisted of saline irrigation mixed with budesonide nasal spray. Outcome measures were both subjective and objective. Sino-Nasal Outcome Test (SNOT-21), Lund-Mackay (LMS), and Lund-Kennedy endoscopic scores (LKES) were taken preoperatively, and at 6 months and 1 year postoperatively. During the same time frames, ACTH and intraocular pressure (IOP) measurements were taken to assure no side effect profile.

Randomization of 60 patients ensued with no statistically significant difference in preoperative measures. Furthermore, both patients and physicians were blinded to the treatment arms. Outcome analysis showed that no statistically significant difference in SNOT-21, LMS, or LKES was appreciated between the treatment arms. Therefore no treatment effect was seen. Furthermore, there was no difference in the ACTH levels or IOP measured with the groups receiving nasal saline alone compared to those also receiving nasal steroids. These results are contrary to the prevailing conventional wisdom that steroids are required to maintain a symptom free patient within the CRSwP population.

Overall, the study was excellent and insightful. The relatively low power of 60 patients and the short follow up period of 1 year in a chronic disease process were potential concerns. The study did reveal that while preoperative medical therapy is extensively studied, postoperative regimens are not. The need for larger studies in the postoperative period is obvious and will prevent treatment regimens based only on experience and conventional thinking.