The diagnosis of AERD should be established prior to surgical intervention by a rm history or a conrmatory challenge. Surgery has been shown to reduce the severity of ASA-/NSAID-induced respiratory reactions [22]. Occasionally, it is not feasible to do this, and the challenge may be performed after the surgery or as part of the desensitization protocol. In this setting, physicians may encounter the clinical dilemma of a “silent desensitization,” referring to a situation in which the patient does not react during aspirin challenge or aspirin desensitization, despite a strong suspicion of AERD.This may be due to several factors, including medications that suppress reactions such as leukotriene modiers and antihistamines, dampening of responses during the immediate postoperative period, and the type of protocol used and/or the timing between doses. There are two strategies that can be employed in this scenario [60]. The rst strategy includes assuming that the patient has AERD and has undergone a silent desensitization. In this strategy, a trial of aspirin therapy can be attempted, and if there is a clinical response, aspirin therapy can be contin­ued. The drawback to this strategy is the remaining question of whether aspirin truly helped, leading to uncertainty regarding need for long-term aspirin use. An alterna­tive strategy would include instructing the patient to stop aspirin for 2weeks and return for a full-dose (325mg) aspirin challenge while off antihistamines, leukotri­ene-receptor antagonists, oral corticosteroids (or lowest possible dose), and mast cell stabilizers for at least 7days. The benet of this strategy is that there is no remaining uncertainty—if the patient reacts during the full-dose challenge, AERD is diagnosed, the reaction is treated, and desensitization can be initiated on the same day. Aspirin therapy would be indicated indenitely, and if the patient does not react, AERD is exceedingly unlikely, and aspirin therapy would not be indicated for its treatment.