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Neuroradiology Case of the Week

Case 346

September 2008

Hisao Nakamura, MD, Ashwani K. Sharma,MD
and P-L Westesson, MD, PhD, DDS

Clinical Presentation: Patient is a 67-year-old female with clinical suspicion for sinus disease.

Imaging Findings: 1) Chronic sinusitis and 2) Post-operative state

Diagnosis: Samter's syndrome

Discussion: This patient has post-nasal polypectomy, aspirin allergy, and recurrent sinusitis. She was diagnosed with Samter's syndrome. Samter's triad or acetylsalicylic acid (ASA) triad is the syndrome of nasal polyposis, asthma and ASA intolerance, which was first described by Widal, et al. in 1922. Samter and Beers (1967) clarified the relationship later [1]. The most plausible basic mechanism underlying sensitivity to aspirin is the inhibition of cyclooxygenase by aspirin and other cyclooxygenase inhibitors could divert the metabolism of arachidonic acid from the cycloxygenase pathway to lipoxygenase pathway, thereby increasing the generation of leukotrienes (LTs) by removing prostaglandin E2 (PGE2) a dominate cycloxygenase product of airways, which has an inhibitory effect on inflammatory cells and pathways. Patients tend to exhibit panmucosal reactivity with reactive mucosa throughout the airway including the tracheobronchial tree and sinuses. The sinus disease is frequently extensive, but can be managed with aggressive medical and surgical therapy. It has been found in 14.8% of patients with nasal polyps [2].

References:

1. Samter M, Beers RF Jr. Concerning the nature of intolerance to aspirin. J Allergy. 1967 Nov;40(5):281-93. [PubMed]
2. Schapowal AG, Simon HU, Schmitz-Schumann M. Phenomenology, pathogenesis, diagnosis and treatment of aspirin-sensitive rhinosinusitis. Acta Otorhinolaryngol Belg. 1995;49(3):235-50. [PubMed]