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- Hi, my name is Dr. Jeffrey Terrell,
I'm a Otolaryngologist or ear, nose, and throat surgeon
at the University of Michigan.
I see a lot of patients with nose and sinus disorders,
and today I'd like to talk about triad asthma,
which is the triad is asthma, nasal polyps,
and aspirin sensitivity.
And I'll try to make this quick, I've got
lots of handouts that I give to patients,
but let me start off with sort of the typical
history of triad asthma, what patients complain about,
what happens to them over time.
And then we'll talk a little bit about treatment.
This is a big topic and I will not cover it all,
but I think it may be helpful to people.
So, triad asthma is a disease that comes on
usually in adults.
People in their twenties, thirties, forties,
people that say:
"I'm totally healthy and then something
"happened to me".
And three things in the triad as I mentioned before are
nasal polyps, asthma, and aspirin sensitivity.
So I can talk about sort of the average presentation,
what people say, what's the order of these things.
Most patients say they start to get some nasal blockage.
And that's the polyps coming on.
And as the polyps get a little bit larger,
they block the olfactory nerves, the sense of smell nerves,
and so they'll start to say
"my sense of smell and my
"ability to taste food, to enjoy food diminishes".
So, your tongue tastes four things, sweet, sour,
salty, and bitter.
But most of what you enjoy about food actually
is the sense of smell.
So people say "my nose plugs up, lost my sense of smell,
"my sense of taste diminishes as well".
And then maybe six weeks, or six months,
or six years later, they'll develop some asthma.
So they'll start coughing and wheezing.
They may hear themselves wheezing at night, or
if they exercise, you go out in the cold,
and then they'll develop asthma, most of them
will go on to need inhalers, several inhalers,
oftentimes a steroid inhaler to control the asthma.
And then finally, a month, or a year, or five
years later, patients will take aspirin for something.
They got an ache or pain, or a fever.
They'll take aspirin, or Motrin, or ibuprofen,
and they will have an allergic reaction to it
where they start wheezing, sometimes get quite
shorter breaths, sometimes end up in the emergency room.
Or their nose will start running and get all stuffy.
And that is the aspirin.
That's the third thing.
That's the aspirin sensitivity and nasal polyps.
I have many patients that come in that have
asthma and nasal polyps, but they haven't
recognized they have or they just haven't had
an aspirin, or Motrin, or non-steroidal
anti-inflammatory drug allergy.
And sometimes they have.
And many doctors haven't recognized or put
all three together.
So that's the triad, again it can come onto people
that are entirely healthy.
And we see these patients for any number of reasons,
but commonly for nasal blockage or decreased sense of smell.
And sometimes the asthma doctors will pick it up.
It turns out that people that have severe asthma,
that a fair number of people with severe asthma,
meaning they were on two or three inhalers all year long,
will develop this aspirin sensitivity.
So certainly, if there's an asthma patient that says
"I can't breathe through my nose" or "I can't smell",
the majority of those patients are going to have
nasal polyps and a lot of them will have
aspirin sensitivity.
It's interesting, the aspirin sensitivity travels
along with patients saying when they drink beer or wine
their nose will just drip and get stuffy and drip as well.
So that's sort of soft call.
Some of these patients will also have clear runny nose
intermittently, especially early in the disease.
The first couple years they'll say:
"I can't lean
"over and write a check because my nose
"might drip unexpectedly".
And they'll also blow out, it sounds a little
unusual, yellow rubbery mucus.
And it's mucus that's really sticky and yellow,
it stretches almost like rubber cement.
Sorry, it's a little bit gross but but it's very unusual,
and these patients do have that.
So, we see these patients in the
Department of Otolaryngology at the University of Michigan,
I see a lot of these patients.
I feel privileged to work with a group of allergists
that help us manage these patients.
And I'll talk just a little bit about how we manage them.
These patients with polyps, they do well with steroids.
And when I mean steroids there could be steroid pills,
there's steroid sprays, there's steroid rinses.
Steroid pills will shrink back the polyps temporarily,
but we don't want to give a lot of steroid pills.
And it's more important that patients be on
some sort of steroid spray or steroid rinse.
So steroid pills will shrink the polyps, but
we really count on them going on steroid, usually
rinses now to keep the polyps down at a controllable level.
But many patients come in, the polyps are quite advanced,
they're quite large, and if we can't control the polyps
and keep their symptoms reasonable, then
we offer endoscopic sinus surgery.
Endoscopic sinus surgery is done with a small
scope, looking in the nose under general anesthesia
so people are totally asleep.
It's an out-patient surgery.
We remove the polyps, we open the sinuses, and open
everything so it drains well.
But it's very important after that that the patients
do steroid rinses and we show them how to do
steroid rinses.
If you've had polyp surgery before and you haven't
been on steroid rinses, if you have asthma,
and nasal polyps, and aspirin sensitivity and you're
not doing steroid rinses, you should consider
getting a second opinion.
Most doctors are doing that now,
but many haven't recognized that patients have asthma
or aspirin sensitivity.
At the University of Michigan, we have been very
fortunate to work with a talented group of allergists,
who offer another line of treatment for these patients
that have aspirin sensitivity, asthma, nasal polyps,
that have the triad asthma, and that's
aspirin desensitization.
Patients will go to see them and they can be desensitized
to aspirin.
That sounds strange.
It's kind of like allergy shots but
not kinda like allergy shots
and it turns out that you could be,
a patient could be desensitized to aspirin.
And when they do that, the polyps don't grow back as fast.
Unfortunately with triad asthma, the polyps
almost always grow back.
But with steroid nasal rinses before and after surgery,
and with aspirin desensitization, patients can
make it a much longer period of time between surgeries.
Also turns out that's interesting, that young patients
with triad asthma tend to have polyps
that grow back very fast.
And somewhat difficult to control sometimes.
And as patients get older, as they have more birthdays
as I say, the polyps don't grow back as fast,
which is kind of fortunate because some of these patients
have had three or five or seven surgeries.
I think it's very important if you have triad asthma,
nasal polyps, certainly anybody with severe asthma,
nasal polyps, that you see somebody that has
some experience doing endoscopic sinus surgery.
And more importantly, managing the patient after surgery
with steroid sprays, maybe aspirin sensitivity.
And I won't talk about some of the new biologic drugs
that are out there.
There's just been starting to get some data about
some new drugs that attack the cells that cause polyps.
But that data is still kind of immature and
I'm not prepared to talk about that until there's
more studies that are out there.
So I hope that's been helpful to you if you have
asthma and nasal polyps, certainly you want to know
if you have aspirin sensitivity.
You can actually be tested for that by an allergist,
by an experienced allergist.
And if you do have triad asthma, you want to consider
some of these treatment modalis and treatment options
that we talked about.
We see a lot of patients with this at the
University of Michigan, and would be delighted to help
anybody that has problems, especially in our area.
Thank you.
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