eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Allergy

Allergic Fungal Sinusitis: Follow-up

Author: John E McClay, MD, Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School
Coauthor(s): Bradley Marple, MD, Vice Chairman, Department of Otolaryngology, University of Texas Southwestern Medical Center
Contributor Information and Disclosures

Updated: Nov 17, 2009

Outcome and Prognosis

The potential for allergic fungal sinusitis (AFS) recidivism is well respected and ranges from 10% to nearly 100%. Recurrence can be in the form of mucosal edema (see Image 15), polyps (see Image 16), scarring, allergic mucin, or fungal debris. However, published rates of allergic fungal sinusitis (AFS) recurrence can be misleading and are highly dependent on length of follow-up study. To emphasize the importance of long-term surveillance, Bent and Kuhn pointed out that, in their experience, the often-dramatic initial response to surgical therapy eventually was replaced by recurrence of allergic fungal sinusitis (AFS) in the absence of ongoing therapy.

Similarly, Kupferburg et al monitored the appearance of sinonasal mucosa of 24 patients treated with combined medical and surgical therapy for allergic fungal sinusitis (AFS). Of the 24 patients, 19 eventually developed recurrence of disease after discontinuation of systemic corticosteroids, but the authors observed that endoscopic evidence of disease generally preceded return of subjective symptoms.

Allergic fungal sinusitis (AFS) recidivism appears to be influenced by long-term postoperative therapy. Schubert and Goetz reported the long-term clinical outcome of 67 patients following initial surgical therapy for allergic fungal sinusitis (AFS). Patients treated with at least 2 months of oral corticosteroids were compared to those who received no corticosteroids. At 1 year following initial surgery, patients treated with oral corticosteroids were significantly less likely to have experienced recurrent allergic fungal sinusitis (AFS; 35%) than those who had not (55%). However, allergic fungal sinusitis (AFS) recidivism remains high despite appropriate postoperative medical therapy. Fungal and nonfungal specific immunotherapy holds some potential as a form of postoperative treatment in patients with allergic fungal sinusitis (AFS), but clinical failures can arise during immunotherapy.

In a review of 42 patients who had received immunotherapy following surgery, Marple et al reported 4 recurrences of disease, which were attributed to noncompliance with immunotherapy or inadequate operative extirpation of allergic fungal mucin.

Future and Controversies

Controversy still exists regarding the exact criteria for diagnosis and the exact regimen for treatment. Although not perfected, recent evidence supports the theory that allergic fungal sinusitis (AFS) represents an immunologic, rather than infectious, disease process. An improved understanding of this underlying disease process has led to an evolution in the treatment of allergic fungal sinusitis (AFS).

Medical therapy has begun to shift from an emphasis on systemic antifungal therapy to various forms of topical treatment and immunomodulation. Likewise, surgical treatment of allergic fungal sinusitis (AFS), still a crucial component of the overall treatment plan of the patient, has shifted from radical to a more conservative but complete, usually endoscopic, approach. Although important, surgery alone does not lead to a long-term disease-free state. A comprehensive management plan incorporating medical, surgical, and immunologic care remains the most likely means of providing long-term disease control for allergic fungal sinusitis (AFS). The exact combination continues to be debated strongly.

 


More on Allergic Fungal Sinusitis

Overview: Allergic Fungal Sinusitis
Workup: Allergic Fungal Sinusitis
Treatment: Allergic Fungal Sinusitis
Follow-up: Allergic Fungal Sinusitis
Multimedia: Allergic Fungal Sinusitis
References
Further Reading
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Further Reading

Clinical guidelines
Committee on Environmental Health, American Academy of Pediatrics, Kim JJ, Mazur LJ. Spectrum of noninfectious health effects from molds. Pediatrics 2006 Dec;118(6):2582-6. 18

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Keywords

sinusitis, fungal sinusitis, allergic fungal sinusitis, allergic Aspergillus sinusitis, allergic aspergillosis of paranasal sinuses, Aspergillus species, AFS, allergic mucin, allergic bronchopulmonary aspergillosis, ABPA, allergic fungal sinusitis, chronic rhinosinusitis, allergic rhinitis, chronic sinusitis, purulent rhinorrhea, sinusitis treatment, sinus infection, sinus problems, allergic sinusitis

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Contributor Information and Disclosures

Author

John E McClay, MD, Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School
John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Bradley Marple, MD, Vice Chairman, Department of Otolaryngology, University of Texas Southwestern Medical Center
Bradley Marple, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, Texas Medical Association, and Triological Society
Disclosure: Nothing to disclose.

Medical Editor

Lanny Garth Close, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons
Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine
Disclosure: Nothing to disclose.

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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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