Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Allergic Fungal Sinusitis Treatment & Management

  • Author: John E McClay, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: May 26, 2016
 

Medical Therapy

On the basis of a postulated schema of the pathophysiology of allergic fungal sinusitis (AFS), a variety of treatment plans addressing its multiple contributing factors has emerged. Medical control of the disease has made use of various combinations of antifungal medications, corticosteroids, and immunotherapy, with varying degrees of disease control. Attempts to control this disease by only partially addressing the underlying causes likely have contributed to a high rate of recidivism. Successful treatment of allergic fungal sinusitis (AFS) requires that the treatment plan account for each factor responsible for the propagation of the disease.

The allergic fungal sinusitis (AFS) cycle suggests that atopy, continuous antigenic exposure, and inflammation all have key roles in the perpetuation of the disease. In theory, individually accounting for each of these factors provides for the best chance of long-term disease control. This comprehensive approach to management depends on complete removal of all fungal mucin (usually requiring surgery) and long-term prevention of recurrence through either immunomodulation (immunotherapy and/or corticosteroids) or fungistatic antimicrobials.

Corticosteroids

The origin of corticosteroid therapy for long-term management of allergic fungal sinusitis (AFS) arose directly from the success of this strategy in the treatment of ABPA. The potent anti-inflammatory and immunomodulatory effects of corticosteroids appear to be well suited to control recurrence of disease. This concept was emphasized by Bent and Kuhn, who noted eventual universal recurrence of allergic fungal sinusitis (AFS) in their patients who were not treated with systemic corticosteroids.[19]

Schubert and Goetz further studied the role of systemic corticosteroids in postoperative management of allergic fungal sinusitis (AFS), demonstrating a significant increase in the time to revision sinus surgery in patients with allergic fungal sinusitis (AFS) who received prolonged courses of postoperative corticosteroids.[20, 21] Postoperative corticosteroid therapy in this study ranged from 2-12 months, with improved outcomes recorded among patients who were placed on longer courses of therapy. However, at present, the optimal dosing regimen and length of therapy remain unclear.

Topical corticosteroids are accepted as standard therapy in the postoperative treatment of allergic fungal sinusitis (AFS), but they possess a limited benefit before surgery because nasal access is restricted. However, after surgery, they may be effective in controlling local inflammation.

Complications of corticosteroids

The well-recognized benefits of systemic corticosteroids are counterbalanced by numerous potential adverse effects, including growth retardation, diabetes mellitus, hypertension, psychotropic effects, gastrointestinal side effects, cataracts, glaucoma, osteoporosis, and aseptic necrosis of the femoral head. Schubert and Goetz noted no adverse effects in their series of 67 patients with allergic fungal sinusitis (AFS) who were treated for up to 1 year with systemic corticosteroids, but long-term follow-up study for this form of therapy is lacking. The adverse effect profile of systemic corticosteroids warrants careful consideration when they are used in a long-term fashion to control allergic fungal sinusitis (AFS).

Topical corticosteroids generally present fewer adverse effects than systemic corticosteroids, based on their limited bioavailability. Long-term use, especially when topical corticosteroids are used at high dosages or in combination with inhaled corticosteroids, presents a risk of hypothalamic-pituitary-adrenal axis suppression, cataract formation, growth retardation, nasal bleeding, and nasal septal perforation in rare cases. As with individuals on any form of long-term therapy, patients using topical corticosteroid sprays should be monitored.

Immunotherapy

The similarity between allergic fungal sinusitis (AFS) and ABPA led to an empiric and theoretical concern that immunotherapy using specific fungal antigens in patients with either of these diseases might incite further allergic reactions by adding to the patient fungal antigenic stimulus. This concern specifically addressed the possible exacerbation of immune complex development and deposition. However, in allergic fungal sinusitis (AFS), surgery is able to remove the inciting fungal load from the paranasal sinuses. Therefore, it recently was postulated that immunotherapy may be beneficial, rather than harmful, as a component of treatment for allergic fungal sinusitis (AFS).

To investigate the safety of fungal immunotherapy as an adjunct to allergic fungal sinusitis (AFS) treatment, a prospective study was performed to examine the response of patients with allergic fungal sinusitis (following adequate surgery) to immunotherapy with all fungal and nonfungal antigens to which the patients were sensitive. In the first year of this study, clinical status was not shown to worsen, patients did not require systemic corticosteroids, most patients were able to discontinue topical corticosteroid therapy, and allergic fungal sinusitis (AFS) recurrence was markedly diminished among patients compliant with the regimen. The follow-up study revealed similar findings at 2 and 3 years.

A complementary study retrospectively compared 11 patients treated in this manner with 11 age- and diseased-matched control subjects who received the same surgical and medical treatment but no immunotherapy. A statistically significant difference was noted between the 2 groups. The cohort receiving immunotherapy as part of their treatment performed better in quality-of-life scores and objective endoscopic measures of mucosal edema.

In a series of 8 patients in whom immunotherapy was given for 3-5 years and then discontinued, no recurrences were seen up to 17 months after discontinuation. Additional study is necessary, but initial work suggests that a role may exist for immunotherapy in the overall treatment strategy for allergic fungal sinusitis (AFS).

Technique of immunotherapy in allergic fungal sinusitis

In initial studies, only immunotherapy for positive fungal antigens was administered for the first 6 months to be certain that any effects (either positive or negative) on the disease process were caused by the administration of fungal antigens. Later, both fungal and nonfungal antigens to which the patient was found to be allergic were included in the treatment mix. However, administering these in 2 separate vials for the first several months of treatment remains advisable to more easily assess the source of any untoward local reaction and to more efficiently advance treatment dosage. After maintenance levels are achieved, the fungal and nonfungal antigens may be combined into one vial.

A common misconception is that only immunotherapy for those fungi identified by culture from allergic fungal mucin should be included in the testing/treatment regimen for a patient. Because of variability in mycology laboratories and circumstances, a positive culture is not obtained for all patients. Conversely, the presence of fungi on culture of sinus contents does not confirm the diagnosis of allergic fungal sinusitis (AFS). One successful approach has been to test for a wide variety of molds (the choice being dictated by experience gained in testing and treating allergy patients in the region) and to include all positive reactors in the treatment set.

Advancement and adjustment of dosage are performed in the usual fashion. Although late local reactions (induration of >30 mm in diameter occurring 24-48 h after an injection) are said to be more common when administering immunotherapy for molds than for other antigens, this has not been the reported experience in treating patients with allergic fungal sinusitis (AFS). Systemic reactions to immunotherapy likewise have not been observed in the UT Southwestern experience.

On the basis of experience, administration of immunotherapy to patients with allergic fungal sinusitis (AFS) is currently recommended for the same duration as that recommended for patients with allergies in general, ie, 3-5 years. Mabry and Marple's protocol at UT Southwestern is listed in Table 4 below. The antigens for which they test and treat are listed in Table 5 below.

Table 4. Protocol for Immunotherapy in Allergic Fungal Sinusitis (Open Table in a new window)

Protocol
1. After successful surgical exenteration of sinuses and confirmation of diagnosis, perform allergy evaluation and testing (RAST or quantitative skin test) for typical panel of nonfungal antigens appropriate for the area. Test (RAST or quantitative skin test) for all relevant molds (fungi) available. Discuss treatment protocol with the patient and obtain informed consent.
2. Instruct the patient in avoidance measures for molds. Adjust pharmacotherapy as necessary.
3. Prepare a vial of all positive nonfungal antigens and a second vial of all positive fungal antigens. Perform a vial test with each.
4. Administer immunotherapy weekly, with dosage advancement as tolerated, placing 1 injection from each vial in a different arm. This allows for accurate recognition of the cause of any local reactions noted.
5. Observe the patient regularly and adjust dosage as necessary if local reactions or adverse changes in nasal signs/symptoms occur. Regularly examine the patient with endoscopy to detect reaccumulation of allergic mucin or reformation of polyps and to ensure that cleaning, medical management, etc, are carried out.
6. As dosage advancement permits (generally by second vial), antigens may be combined into 1 vial; continue for a 3- to 5-year regimen according to standard practice.
Reproduced from Mabry RL, 1998.

Table 5. Fungal Antigens in Current Testing and Treatment Protocol at the University of Texas Southwestern Medical Center at Dallas (Open Table in a new window)

Fungal Antigens in Approximate Relative Order of Local (Dallas, TX) Importance
Helminthosporium
Alternaria
Stemphyllium
Curvularia
Aspergillus
Epicoccum
Fusarium
Mucor
Pullularia
Cladosporium
Penicillium
Reproduced from Mabry RL, 1998.

Complications of immunotherapy

Currently, no treatment-related complications have been identified when immunotherapy follows appropriate surgical extirpation of all allergic mucin. However, this finding should not promote a sense of false security concerning this form of therapy because immunotherapy continues to represent a new and incompletely understood treatment modality. In general terms, immunotherapy may lead to worsening of local or systemic disease, specifically if the patient continues to be exposed to a significant antigenic load.

Ferguson reported 7 patients who received immunotherapy for the treatment of allergic fungal sinusitis (AFS). The 5 patients who received immunotherapy before surgical removal of all allergic mucin either symptomatically worsened or failed to improve in response to therapy. In contrast to these findings, the 2 patients who underwent surgery before initiation of immunotherapy responded well to this treatment modality. This small study supports the concept that immunotherapy administered in the presence of an ongoing antigenic load (in this case, fungus) raises the risk of untoward complications of therapy (eg, immune complex deposition, delayed or late-phase reactions, local reactions).

Another permutation of this concern occurs when allergic fungal sinusitis (AFS) presents concomitantly with ABPA. Unlike in allergic fungal sinusitis (AFS), the fungi within the lower respiratory tract of patients with ABPA cannot be surgically removed, thereby resulting in a retained antigenic load. Moreover, while clinical manifestations of allergic fungal sinusitis (AFS) sometimes are dramatic, they rarely are life threatening. The threat of ABPA potentially is much greater. Given the lack of information regarding the effects of immunotherapy on ABPA, great care should be taken when immunotherapy is given in this situation.

Antifungals

Systemic antifungal therapy for allergic fungal sinusitis (AFS) initially was proposed to control the theoretical potential for progression to invasive forms of fungal sinusitis. As the unacceptably high rate of recidivism following surgery alone was recognized, antifungal therapy often was used in an attempt to provide some degree of control over recurrence of allergic fungal sinusitis (AFS). Early use of amphotericin B yielded to the use of less toxic agents, such as ketoconazole, itraconazole, and fluconazole, but the poor in vivo activity of these agents against dematiaceous fungi soon was discovered.

Objective data on the effects of this form of therapy for allergic fungal sinusitis (AFS) have been limited. Denning et al studied the effect of systemic itraconazole in patients with ABPA and demonstrated a decrease in total IgE (used as a marker of disease severity) and in systemic corticosteroid requirements.[22] Anecdotal reports of systemic itraconazole to prevent allergic fungal sinusitis (AFS) recurrence offer mixed results. Ferguson points out that the expense, limited available data, and potential drug-related morbidity of systemic antifungal therapy may limit the usefulness of this form of treatment for noninvasive fungal disease.

Topical application of antifungal agents may hold some benefit in the control of postoperative recurrence, and studies of this form of treatment currently are underway. Bent and Kuhn studied the in vitro susceptibility of fungi commonly encountered in patients with allergic fungal sinusitis (AFS) and determined that minimal inhibitory concentrations can be exceeded with certain antifungal agents when applied topically. Similarly, Ponikau et al support the use of topical antifungal agents. Supportive data are pending.

Complications of antifungal therapy

Antifungal medications are recognized for some potentially serious adverse effects, which warrant consideration when these medications are used as a form of treatment for AFS. The well-known complications associated with amphotericin B include acute renal failure, anemia, agranulocytosis, acute liver failure, cardiopulmonary hypertension, and hemorrhagic gastroenteritis. Itraconazole and fluconazole offer a slightly safer form of antifungal therapy but still may give rise to drug-induced cardiac dysrhythmias, hepatic dysfunction, urticaria, and anaphylaxis.

Next

Surgical Therapy

The invariable components of combination therapy still are surgical removal of the inciting fungal allergic mucin and marsupialization of the involved sinuses. For this reason, surgery has played an important role in the management of allergic fungal sinusitis (AFS) since its earliest reports. An aggressive surgical posture initially was adopted because of a perceived risk of fungal invasion. This frequently was accomplished through the use of open antrostomies with radical removal of mucosa, intranasal sphenoethmoidectomies, and Lynch frontoethmoidectomies. Despite such aggressive therapy, recidivism remained high, and most patients required multiple surgical procedures.

Clinical appearance of the disease often confused the underlying diagnosis, further influencing surgeons to adopt a more radical stance. Radiographic evidence of invasion (which really was extension) into adjacent spaces (eg, orbit, intracranial cavity) frequently was interpreted as evidence of malignancy or invasive fungal disease. It logically followed that surgical approaches appropriate for these serious conditions (eg, lateral rhinotomy, facial degloving approaches, craniofacial resection) would be performed.

Increased acceptance of specific immunologic hypersensitivity as the cause of allergic fungal sinusitis (AFS) has led to changes in its management. These changes have involved the medical and surgical arms of therapy. While systemic use of antifungal medications largely has been replaced by immunomodulation, radical surgery for allergic fungal sinusitis (AFS) has given way to more conservative tissue-sparing approaches. Mabry et al refer to this surgery as conservative but complete, relying almost completely on endoscopic techniques.

Previous
Next

Preoperative Details

To minimize recurrence of disease, treatment of allergic fungal sinusitis (AFS) is directed at removal of the inciting antigenic material via complete surgical removal of allergic mucin and debris while also ameliorating the underlying inflammatory process through the use of limited systemic and topical steroid preparations. One accepted preoperative medical regimen is to initiate systemic corticosteroid therapy (prednisone dosed at 0.5-1 mg/kg/d) approximately 1 week before surgery to decrease intranasal inflammation and nasal polyp volume. Bleeding encountered at surgery following preoperative steroids also is reduced. Additionally, preoperative antibiotics are instituted because of the frequency of concomitant postobstructive bacterial sinusitis.

Previous
Next

Intraoperative Details

At surgery, 3 surgical goals should be achieved: (1) complete extirpation of all allergic mucin and fungal debris, (2) permanent drainage and ventilation of the affected sinuses while preserving the integrity of the underlying mucosa, and (3) postoperative access to the previously diseased areas.

First, surgery should result in complete extirpation of all allergic mucin and fungal debris, thus greatly reducing or eliminating the antigenic inciting factor within the atopic individual, as depicted in the image below. At times, this may be challenging because the nasal polyposis inherent in allergic fungal sinusitis (AFS) can range from subtle to extensive, causing distortion of local anatomy and loss of useful surgical landmarks. Bleeding often occurs in response to surgical manipulation of the polyps, increasing the potential for disorientation. The operating surgeon must recognize that these factors, in combination with the high likelihood of bony dehiscence, increase the risk of iatrogenic injury.

Immediate postoperative 30° angled view showing th Immediate postoperative 30° angled view showing the complete removal of polyps with a widened frontal sinus recess superiorly and widened ethmoid cavity in the mid portion. The middle turbinate is on the right, pushed against the septum. The lateral nasal wall is on the left.

Aside from these problems, polyps can provide an important intraoperative role by serving as a marker of disease. Allergic fungal sinusitis (AFS) causes a relatively consistent configuration of disease. The involved paranasal sinus, acting as a reservoir for allergic fungal mucin, is the epicenter of the disease process. Allergic fungal mucin completely occupies the sinus cavity and almost always is mixed with fungal elements, as depicted in the images below, while the lining mucosa, demonstrating only mild-to-moderate inflammation, remains an intact barrier to the fungus. More significant inflammation located at the sinus ostia gives rise to polyps that extend into the infundibulum, middle meatus, sphenoethmoid recess, and nasal cavity. Recognition of this allows the surgeon to follow the polyps to the disease.

Fungal ball in the right maxillary sinus. Fungal ball in the right maxillary sinus.
Fungal debris being removed from the ethmoid compl Fungal debris being removed from the ethmoid complex. A suction device is seen in the right lower corner of the picture.
Allergic mucin, fungal debris, and polyps are show Allergic mucin, fungal debris, and polyps are shown after removal from the patient. The scale is in inches.

The allergic mucin, not the polyps, should be sent to a pathologist to confirm the diagnosis of allergic fungal sinusitis (AFS; see Histologic Findings). The fungal elements and mucin can be sent for culture and pathologic stain to help make the diagnosis and identify the fungus responsible for the disease. Fungal stains are positive more often than fungal cultures, but both should be attempted.

Resulting nasal polyposis also can facilitate surgical treatment of allergic fungal sinusitis (AFS) in another fashion. The expansile behavior of allergic fungal sinusitis (AFS) increases access to involved paranasal sinuses. As revealed radiographically, the combination of slowly growing nasal polyps and accumulating allergic fungal mucin expands the involved paranasal sinuses and the surgical route to the involved sinuses. Enlargement of the nasal cavity, middle meatus, and frontal recess provides the surgeon with access adequate to address the disease, even in the most difficult areas, such as the lateral area of the frontal sinus, which once was thought to require a traditional nonendoscopic approach, as depicted in the image below.

Coronal CT scan showing extensive allergic fungal Coronal CT scan showing extensive allergic fungal sinusitis involving the right side with mucocele above the right orbit and expansion of the sinuses on the right.
Coronal CT scan showing the postoperative view fol Coronal CT scan showing the postoperative view following removal of disease after significant disease recurred on both the right and left sides of the nasal cavity and sinuses; mild mucosal thickening of all involved sinuses is present, with some moderate thickening of the left maxillary sinus. All disease, even the lateral mucocele, was removed or drained endoscopically.

After surgical access to the involved sinus is achieved, a dilated cavity filled with allergic fungal mucin is encountered. This material is thick, tenacious, and viscous and may vary in color from light tan to black. Because of its noninvasive behavior, it may be removed in a blunt fashion, leaving the involved sinus completely lined with intact mucosa. Preservation of mucosa provides protection of adjacent anatomic structures, even in the face of large areas of bony dehiscence.

The next goal of surgery is to produce permanent drainage and ventilation of the affected sinuses while preserving the integrity of the underlying mucosa. This has been aided greatly by the recent advent of tissue-sparing instrumentation. Even in the setting of significant dissolution of the fovea ethmoidalis, lamina papyracea, clivus, and sphenoid planum, wide marsupialization of diseased areas can be achieved without causing trauma to the underlying mucosa. Careful preservation of mucosa ensures that underlying periosteum, dura, and/or periorbita remain free of penetrating injury. Sinonasal polyposis initially may preclude orientation, but removal in a controlled fashion using powered microdissection provides the operating surgeon with eventual access to areas of fungal presence. After adequate ventilation and drainage are achieved, the preserved underlying mucosa is able to revert to its normal state.

Adequate ventilation and drainage also provide for the final goal of surgery, postoperative access to the previously diseased areas. Even under ideal conditions, small residua of fungus may remain in situ, inciting recurrence if not controlled postoperatively. Surgery should be performed with facilitation of postsurgical care in mind. This goal can be attained reliably in most patients while preserving the integrity of important intranasal structures, such as the middle and inferior turbinates.

These surgical goals can be accomplished through a number of approaches and techniques, the choice of which ultimately is influenced by the experience and training of the surgeon. Endoscopic powered instrumentation has demonstrated its effectiveness; this technique allows for removal of soft tissue and thin bone while maintaining superb visibility. Exercise great care when using powered instrumentation because the well-recognized bone dissolution associated with allergic fungal sinusitis (AFS) increases the potential risk of inadvertent orbital and/or intracranial penetration. In the event of extensive remodeling or bone erosion, image-guided systems (eg, Stealth, InstaTrak) may be of benefit.

Previous
Next

Postoperative Details

Postoperative care begins immediately following surgery with nasal saline irrigation with bulb irrigations or Water-Pic, with or without the Grossan adaptor. Sinus packing usually is not needed, but the need is evaluated on an individual basis. Weekly clinic visits for about a month initially are required to allow regular inspection of the operative site and debridement of crusts and retained fungal debris.

Systemic corticosteroids, which were initiated before surgery, are continued during the postoperative period and slowly tapered during the process of healing. The length of corticosteroid treatment and the form of postoperative adjunctive medical management used to further control the disease are at the discretion of the managing physician. The authors typically treat the patients with 3-4 weeks of steroids postoperatively, starting with a similar dose of steroids received preoperatively for 10-14 days. The steroids then are tapered over the next 10-14 days. Topical nasal steroids are started at the first postoperative visit, continued until immunotherapy is well established, and used thereafter as needed.

Previous
Next

Follow-up

Postoperative follow-up care for the first month is noted above. No set interval is established for follow-up visits after the postoperative regimen. However, the author has started requesting patient follow-up visits at 3-month intervals to detect recurrences early because recurrence is not uncommon. Immunotherapy is always recommended for these patients, thus they are monitored closely by the physician, usually an allergist, who is instituting the injections. If symptoms of sinusitis or nasal airway obstruction return, rigid or flexible rhinoscopy in the clinic or CT should be performed to evaluate for recurrent disease.

Previous
Next

Complications

In most patients, surgery is performed without incident, but the pathologic behavior of allergic fungal sinusitis (AFS) theoretically increases surgical risk. Nasal polyposis, expansile accumulations of allergic mucin, and poor intraoperative hemostasis may increase spatial disorientation. Additionally, areas of bony dehiscence may confuse or distort anatomic boundaries while offering little protection to the orbit and intracranial cavities. Conversely, a less than complete surgical procedure (in an attempt to decrease iatrogenic injury) is likely to lead to incomplete retrieval of allergic fungal mucin and rapid recurrence of allergic fungal sinusitis (AFS).

On the basis of currently accepted pathophysiology of allergic fungal sinusitis (AFS), little risk of fungal invasion into adjacent tissues should exist in an immunocompetent host. However, rare exceptions may occur. Tsimikas et al report a single case of an Aspergillus frontal lobe abscess that occurred following surgical treatment of allergic fungal sinusitis (AFS) that had expanded into the anterior cranial fossa.[23, 24] This case may represent seeding of the intracranial cavity as a result of inadvertent dural penetration, and it emphasizes the importance of mucosal preservation.

In addition to fungal or bacterial seeding, penetration of the dura or periorbita iatrogenically during surgery may result in injury of structures within the orbit or intracranial cavities. Such transgressions can cause diplopia, blindness, hemorrhage, stroke, intracranial hemorrhage, encephalocele, and/or cerebrospinal fluid (CSF) rhinorrhea (see the Medscape article Pediatric Sinusitis Surgery).

Erosion by allergic fungal sinusitis (AFS) of the osseous boundaries separating the intracranial fossa from the sinonasal cavities may increase the risk of subsequent encephalocele formation. The otologic community commonly accepts that dural exposure in the absence of dural injury along the tegmen mastoideum rarely results in development of an encephalocele. Unfortunately, no analogous information within the rhinologic literature exists. However, it is logical to assume that eventual encephalocele formation may occur as a result of a combination of factors, including dural injury, location of bony dehiscence, and/or size of the bony dehiscence. In rare cases, accumulations of allergic fungal mucin actually may appear to support intracranial structures. Monitoring for development of encephaloceles is important, because their occurrence may require subsequent repair of bony dehiscence.

Previous
Next

Outcome and Prognosis

A retrospective study in North Carolina by Miller et al indicated that various socioeconomic factors, including low income, residency in rural areas, low-quality housing, and reduced access to health care, are associated with the severity of allergic fungal sinusitis (AFS). The investigators, whose study involved 93 patients, determined that the prevalence of AFS-associated bone erosion was greater in patients living in counties with a lower per-capita income or with older, poorer-quality housing, while patients with orbitocranial involvement tended to be found in rural counties with fewer primary care providers per capita. The study also concluded, however, that disease severity did not correlate with patients’ race, age, gender, or insurance status.[25] The potential for AFS recidivism is well respected and ranges from 10% to nearly 100%. Recurrence can be in the form of mucosal edema, as depicted in the 1st image below, polyps as depicted in the 2nd image below, 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.

Two-week postoperative endoscopic picture showing Two-week postoperative endoscopic picture showing polypoid thickening already in the ethmoid cavities while the patient was still on tapering steroids; on the left is the lateral nasal wall. The right shows the middle turbinate next to the septum.
A polypoid recurrence in the center of the ethmoid A polypoid recurrence in the center of the ethmoid cavity. The septum is on the left.

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.

Previous
Next

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.

Previous
 
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 Center

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, 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, Triological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

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 Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, New York Academy of Medicine

Disclosure: Nothing to disclose.

References
  1. Glass D, Amedee RG. Allergic fungal rhinosinusitis: a review. Ochsner J. 2011 Fall. 11(3):271-5. [Medline]. [Full Text].

  2. Safirstein BH. Allergic bronchopulmonary aspergillosis with obstruction of the upper respiratory tract. Chest. 1976 Dec. 70(6):788-90. [Medline].

  3. Robson JM, Hogan PG, Benn RA, et al. Allergic fungal sinusitis presenting as a paranasal sinus tumour. Aust N Z J Med. 1989 Aug. 19(4):351-3. [Medline].

  4. Loury MC, Leopold DA, Schaefer SD. Allergic Aspergillus sinusitis. Arch Otolaryngol Head Neck Surg. 1993 Sep. 119(9):1042-3. [Medline].

  5. Cody DT 2nd, Neel HB 3rd, Ferreiro JA, et al. Allergic fungal sinusitis: the Mayo Clinic experience. Laryngoscope. 1994 Sep. 104(9):1074-9. [Medline].

  6. Bent JP 3rd, Kuhn FA. Allergic fungal sinusitis/polyposis. Allergy Asthma Proc. 1996 Sep-Oct. 17(5):259-68. [Medline].

  7. Deshpande RB, Shukla A, Kirtane MV. Allergic fungal sinusitis: incidence and clinical and pathological features of seven cases. J Assoc Physicians India. 1995 Feb. 43(2):98-100. [Medline].

  8. McClay JE, Marple B, Kapadia L, et al. Clinical presentation of allergic fungal sinusitis in children. Laryngoscope. 2002 Mar. 112(3):565-9. [Medline].

  9. Manning SC, Holman M. Further evidence for allergic pathophysiology in allergic fungal sinusitis. Laryngoscope. 1998 Oct. 108(10):1485-96. [Medline].

  10. Feger TA, Rupp NT, Kuhn FA, et al. Local and systemic eosinophil activation in allergic fungal sinusitis. Ann Allergy Asthma Immunol. 1997 Sep. 79(3):221-5. [Medline].

  11. Lu-Myers Y, Deal AM, Miller JD, et al. Comparison of Socioeconomic and Demographic Factors in Patients with Chronic Rhinosinusitis and Allergic Fungal Rhinosinusitis. Otolaryngol Head Neck Surg. 2015 Apr 27. [Medline].

  12. Mostafa Bel-D, Taha MS, Abdel Hamid T, Omran A, Lotfi N. Evaluation of vitamin D levels in allergic fungal sinusitis, chronic rhinosinusitis, and chronic rhinosinusitis with polyposis. Int Forum Allergy Rhinol. 2016 Feb. 6 (2):185-90. [Medline].

  13. White LC, Jang DW, Yelvertan JC, Kountakis SE. Bony erosion patterns in patients with allergic fungal sinusitis. Am J Rhinol Allergy. 2015 Jul-Aug. 29 (4):243-5. [Medline].

  14. Marple BF, Gibbs SR, Newcomer MT, Mabry RL. Allergic fungal sinusitis-induced visual loss. Am J Rhinol. 1999 May-Jun. 13(3):191-5. [Medline].

  15. Gupta R, Gupta AK, Patro SK, et al. Allergic fungal rhino sinusitis with granulomas: A new entity?. Med Mycol. 2015 May 30. [Medline].

  16. Reddy CE, Gupta AK, Singh P, Mann SB. Imaging of granulomatous and chronic invasive fungal sinusitis: comparison with allergic fungal sinusitis. Otolaryngol Head Neck Surg. 2010 Aug. 143(2):294-300. [Medline].

  17. Zinreich SJ, Kennedy DW, Malat J, et al. Fungal sinusitis: diagnosis with CT and MR imaging. Radiology. 1988 Nov. 169(2):439-44. [Medline].

  18. Millar J, Lamb D. Allergic bronchopulmonary aspergillosis of the maxillary sinuses. Thorax. 1981. 36:710.

  19. Bent JP 3rd, Kuhn FA. Antifungal activity against allergic fungal sinusitis organisms. Laryngoscope. 1996 Nov. 106(11):1331-4. [Medline].

  20. Schubert MS, Goetz DW. Evaluation and treatment of allergic fungal sinusitis. I. Demographics and diagnosis. J Allergy Clin Immunol. 1998 Sep. 102(3):387-94. [Medline].

  21. Schubert MS, Goetz DW. Evaluation and treatment of allergic fungal sinusitis. II. Treatment and follow-up. J Allergy Clin Immunol. 1998 Sep. 102(3):395-402. [Medline].

  22. Denning DW, Van Wye JE, Lewiston NJ, et al. Adjunctive therapy of allergic bronchopulmonary aspergillosis with itraconazole. Chest. 1991 Sep. 100(3):813-9. [Medline].

  23. Tsimikas S, Hollingsworth HM, Nash G. Aspergillus brain abscess complicating allergic Aspergillus sinusitis. J Allergy Clin Immunol. 1994 Aug. 94(2 Pt 1):264-7. [Medline].

  24. Holbrook JF, Eastwood JD, Kilani RK. Intracranial Abscess as a Complication of Allergic Fungal Sinusitis. J Neuroimaging. 2011 Dec 30. [Medline].

  25. Miller JD, Deal AM, McKinney KA, et al. Markers of disease severity and socioeconomic factors in allergic fungal rhinosinusitis. Int Forum Allergy Rhinol. 2014 Apr. 4(4):272-9. [Medline].

  26. Kim JJ, Mazur LJ. Spectrum of noninfectious health effects from molds. Pediatrics. 2006 Dec. 118(6):2582-6. [Medline].

  27. Allphin AL, Strauss M, Abdul-Karim FW. Allergic fungal sinusitis: problems in diagnosis and treatment. Laryngoscope. 1991 Aug. 101(8):815-20. [Medline].

  28. Bent JP 3rd, Kuhn FA. Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1994 Nov. 111(5):580-8. [Medline].

  29. Berrettini S, Carabelli A, Papini M, et al. [Allergic fungal sinusitis: is this rare disease an allergy or infection?]. Acta Otorhinolaryngol Ital. 1996 Oct. 16(5):447-54. [Medline].

  30. Chrzanowski RR, Rupp NT, Kuhn FA, et al. Allergenic fungi in allergic fungal sinusitis. Ann Allergy Asthma Immunol. 1997 Nov. 79(5):431-5. [Medline].

  31. Collins M, Nair S, Smith W, et al. Role of local immunoglobulin E production in the pathophysiology of noninvasive fungal sinusitis. Laryngoscope. 2004 Jul. 114(7):1242-6. [Medline].

  32. Corey JP. Allergic fungal sinusitis. Otolaryngol Clin North Am. 1992 Feb. 25(1):225-30. [Medline].

  33. deShazo RD, O'Brien M, Chapin K, et al. Criteria for the diagnosis of sinus mycetoma. J Allergy Clin Immunol. 1997 Apr. 99(4):475-85. [Medline].

  34. deShazo RD, Swain RE. Diagnostic criteria for allergic fungal sinusitis. J Allergy Clin Immunol. 1995 Jul. 96(1):24-35. [Medline].

  35. Ferguson BJ. Categorization of eosinophilic chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg. 2004 Jun. 12(3):237-42. [Medline].

  36. Ferguson BJ. Immunotherapy and antifungal therapy in allergic fungal sinusitis. Presented at: Annual Meeting of the American Academy. of Otolaryngic Allergy; Minneapolis, Minn. 1993.

  37. Ferguson BJ. What role do systemic corticosteroids, immunotherapy, and antifungal drugs play in the therapy of allergic fungal rhinosinusitis?. Arch Otolaryngol Head Neck Surg. 1998 Oct. 124(10):1174-8. [Medline].

  38. Folker RJ, Marple BF, Mabry RL, et al. Treatment of allergic fungal sinusitis: a comparison trial of postoperative immunotherapy with specific fungal antigens. Laryngoscope. 1998 Nov. 108(11 Pt 1):1623-7. [Medline].

  39. Gourley DS, Whisman BA, Jorgensen NL, et al. Allergic Bipolaris sinusitis: clinical and immunopathologic characteristics. J Allergy Clin Immunol. 1990 Mar. 85(3):583-91. [Medline].

  40. Graham SM, Carter KD. Response of visual loss in allergic fungal sinusitis to oral corticosteroids. Ann Otol Rhinol Laryngol. 2005 Mar. 114(3):247-9. [Medline].

  41. Greenberger P, Atkinson NF Jr, Yunginger JW, et al. Allergic bronchopulmonary aspergillosis. Middleton E, Reed C, Ellis E, et al, eds. Allergy Principles and Practice. St. Louis: Mosby; 1993. 1395-1414.

  42. Gungor A, Adusumilli V, Corey JP. Fungal sinusitis: progression of disease in immunosuppression--a case report. Ear Nose Throat J. 1998 Mar. 77(3):207-10, 215. [Medline].

  43. Healy DY, Leid JG, Sanderson AR, et al. Biofilms with fungi in chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2008 May. 138(5):641-7. [Medline].

  44. Jackson CG, Pappas DG Jr, Manolidis S, et al. Brain herniation into the middle ear and mastoid: concepts in diagnosis and surgical management. Am J Otol. 1997 Mar. 18(2):198-205; discussion 205-6. [Medline].

  45. Katzenstein AL, Sale SR, Greenberger PA. Allergic Aspergillus sinusitis: a newly recognized form of sinusitis. J Allergy Clin Immunol. 1983 Jul. 72(1):89-93. [Medline].

  46. Katzenstein AL, Sale SR, Greenberger PA. Pathologic findings in allergic aspergillus sinusitis. A newly recognized form of sinusitis. Am J Surg Pathol. 1983 Jul. 7(5):439-43. [Medline].

  47. King HC, Mabry RL, Mabry CS. Allergy in ENT Practice. NY: Thieme Medical Publishers; 1998. 227-42.

  48. Kinsella JB, Rassekh CH, Bradfield JL, et al. Allergic fungal sinusitis with cranial base erosion. Head Neck. 1996 May-Jun. 18(3):211-7. [Medline].

  49. Kuhn FA. Role of endoscopy in the management of chronic rhinosinusitis. Ann Otol Rhinol Laryngol Suppl. 2004 May. 193:15-8. [Medline].

  50. Kuhn FA, Swain R. Allergic fungal sinusitis: diagnosis and treatment. Curr Opin Otolaryngol Head Neck Surg. 2003 Feb. 11(1):1-5. [Medline].

  51. Kupferberg SB, Bent JP. Allergic fungal sinusitis in the pediatric population. Arch Otolaryngol Head Neck Surg. 1996 Dec. 122(12):1381-4. [Medline].

  52. Kupferberg SB, Bent JP 3rd, Kuhn FA. Prognosis for allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1997 Jul. 117(1):35-41. [Medline].

  53. Lamb D, Millar J, Johnston A. Allergic aspergillosis of the paranasal sinuses. J Pathol. 1982. 137:56.

  54. Liu JK, Schaefer SD, Moscatello AL, et al. Neurosurgical implications of allergic fungal sinusitis. J Neurosurg. 2004 May. 100(5):883-90. [Medline].

  55. Mabry RL, Mabry CS. Immunotherapy for allergic fungal sinusitis: the second year. Otolaryngol Head Neck Surg. 1997 Oct. 117(4):367-71. [Medline].

  56. Mabry RL, Manning S. Radioallergosorbent microscreen and total immunoglobulin E in allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1995 Dec. 113(6):721-3. [Medline].

  57. Mabry RL, Manning SC, Mabry CS. Immunotherapy in the treatment of allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1997 Jan. 116(1):31-5. [Medline].

  58. Mabry RL, Marple BF, Folker RJ, et al. Immunotherapy for allergic fungal sinusitis: three years' experience. Otolaryngol Head Neck Surg. 1998 Dec. 119(6):648-51. [Medline].

  59. Mabry RL, Marple BF, Mabry CS. Mold testing by RAST and skin test methods in patients with allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1999 Sep. 121(3):252-4. [Medline].

  60. Mabry RL, Marple BF, Mabry CS. Outcomes after discontinuing immunotherapy for allergic fungal sinusitis. Otolaryngol Head Neck Surg. 2000 Jan. 122(1):104-6. [Medline].

  61. Manning SC, Mabry RL, Schaefer SD, et al. Evidence of IgE-mediated hypersensitivity in allergic fungal sinusitis. Laryngoscope. 1993 Jul. 103(7):717-21. [Medline].

  62. Manning SC, Merkel M, Kriesel K, et al. Computed tomography and magnetic resonance diagnosis of allergic fungal sinusitis. Laryngoscope. 1997 Feb. 107(2):170-6. [Medline].

  63. Manning SC, Vuitch F, Weinberg AG, et al. Allergic aspergillosis: a newly recognized form of sinusitis in the pediatric population. Laryngoscope. 1989 Jul. 99(7 Pt 1):681-5. [Medline].

  64. Marple BF. Allergic fungal rhinosinusitis: surgical management. Otolaryngol Clin North Am. 2000 Apr. 33(2):409-19. [Medline].

  65. Marple BF. Allergic fungal sinusitis. Current opinion in otolaryngology & head and neck surgery. 1999. 7:383-387.

  66. Marple BF, Mabry RL. Allergic fungal sinusitis: learning from our failures. Am J Rhinol. 2000 Jul-Aug. 14(4):223-6. [Medline].

  67. Marple BF, Mabry RL. Comprehensive management of allergic fungal sinusitis. Am J Rhinol. 1998 Jul-Aug. 12(4):263-8. [Medline].

  68. McClay JE, Marple BF, Kapadia L, et al. Presented at: The American Society of. Clinical presentation of allergic fungal sinusitis in children. Orlando, Fla: Pediatric Otolaryngology; 2000.

  69. Medical Economics Staff. Physicians' Desk Reference. 53rd ed. 1999.

  70. Mirante JP, Krouse JH, Munier MA, et al. The role of powered instrumentation in the surgical treatment of allergic fungal sinusitis. Ear Nose Throat J. 1998 Aug. 77(8):678-80, 682. [Medline].

  71. Mukherji SK, Figueroa RE, Ginsberg LE, et al. Allergic fungal sinusitis: CT findings. Radiology. 1998 May. 207(2):417-22. [Medline].

  72. Nussenbaum B. Presented at: Southern Section of the American Laryngological, Rhinological, and Otological Society, Inc.; Abstract. St. Petersburg, Fla: 2000.

  73. Ponikau JU, Sherris DA, Kern EB, et al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc. 1999 Sep. 74(9):877-84. [Medline].

  74. Rains BM 3rd, Mineck CW. Treatment of allergic fungal sinusitis with high-dose itraconazole. Am J Rhinol. 2003 Jan-Feb. 17(1):1-8. [Medline].

  75. Ramadan HH, Quraishi HA. Allergic mucin sinusitis without fungus. Am J Rhinol. 1997 Mar-Apr. 11(2):145-7. [Medline].

  76. Revankar SG. Dematiaceous fungi. Mycoses. 2007 Mar. 50(2):91-101. [Medline].

  77. Schnadig VJ, Rassekh CH, Gourley WK. Allergic fungal sinusitis. A report of two cases with diagnosis by intraoperative aspiration cytology. Acta Cytol. 1999 Mar-Apr. 43(2):268-72. [Medline].

  78. Schubert MS. Allergic fungal sinusitis. Otolaryngol Clin North Am. 2004 Apr. 37(2):301-26. [Medline].

  79. Schubert MS. Allergic fungal sinusitis: pathogenesis and management strategies. Drugs. 2004. 64(4):363-74. [Medline].

  80. Sher TH, Schwartz HJ. Allergic Aspergillus sinusitis with concurrent allergic bronchopulmonary Aspergillus: report of a case. J Allergy Clin Immunol. 1988 May. 81(5 Pt 1):844-6. [Medline].

  81. Som PM, Curtin HD. Chronic inflammatory sinonasal diseases including fungal infections. The role of imaging. Radiol Clin North Am. 1993 Jan. 31(1):33-44. [Medline].

  82. Stonebraker AC, Schlosser RJ. Orbital volumetric analysis of allergic fungal sinusitis patients with proptosis before and after endoscopic sinus surgery. Am J Rhinol. 2005 May-Jun. 19(3):302-6. [Medline].

  83. Thakar A, Sarkar C, Dhiwakar M, et al. Allergic fungal sinusitis: expanding the clinicopathologic spectrum. Otolaryngol Head Neck Surg. 2004 Feb. 130(2):209-16. [Medline].

  84. Torres C, Ro JY, el-Naggar AK, et al. Allergic fungal sinusitis: a clinicopathologic study of 16 cases. Hum Pathol. 1996 Aug. 27(8):793-9. [Medline].

  85. Travis WD, Kwon-Chung KJ, Kleiner DE, et al. Unusual aspects of allergic bronchopulmonary fungal disease: report of two cases due to Curvularia organisms associated with allergic fungal sinusitis. Hum Pathol. 1991 Dec. 22(12):1240-8. [Medline].

  86. Wise SK, Ghegan MD, Gorham E, et al. Socioeconomic factors in the diagnosis of allergic fungal rhinosinusitis. Otolaryngol Head Neck Surg. 2008 Jan. 138(1):38-42. [Medline].

  87. Wise SK, Venkatraman G, Wise JC, et al. Ethnic and gender differences in bone erosion in allergic fungal sinusitis. Am J Rhinol. 2004 Nov-Dec. 18(6):397-404. [Medline].

  88. Young CN, Swart JG, Ackermann D, et al. Nasal obstruction and bone erosion caused by Drechslera hawaiiensis. J Laryngol Otol. 1978 Feb. 92(2):137-43. [Medline].

 
Previous
Next
 
Left middle meatus with suctioning of thick allergic mucin from the ethmoid bulla in the center of the picture; the end of the suction is in the inferior portion of the picture.
The viscosity of a thick allergic mucin being suctioned from the nasal cavity and vestibule in a patient with allergic fungal sinusitis.
View just inside the nasal vestibule showing diffused polyposis extending into the anterior nasal cavity and vestibule; the septum is on the right, and the right lateral vestibular wall (nasal ala) is on the left. The polyps all are in the center. The polyps almost hang out of the nasal vestibule.
A 15-year-old boy with allergic fungal sinusitis causing right proptosis, telecanthus, and malar flattening; the position of his eyes is asymmetrical, and his nasal ala on the right is pushed inferiorly compared to the left.
A 9-year-old girl with allergic fungal sinusitis displaying telecanthus and asymmetrical positioning of her eyes and globes.
Coronal CT scan showing extensive allergic fungal sinusitis involving the right side with mucocele above the right orbit and expansion of the sinuses on the right.
Typical view of a middle meatus in a patient with allergic fungal sinusitis with expansion of the ethmoid complex and extension of the middle turbinate more inferiorly. This is a postoperative view.
Coronal CT scan showing typical unilateral appearance of allergic fungal sinusitis with hyperintense areas and inhomogeneity of the sinus opacification; the hyperintense areas appear whitish in the center of the allergic mucin.
Coronal MRI showing expansion of the sinuses with allergic mucin and polypoid disease; the hypointense black areas in the nasal cavities are the actual fungal elements and debris. The density above the right eye is the mucocele. The fungal elements and allergic mucin in allergic fungal sinusitis always look hypointense on MRI scanning and can be mistaken for absence of disease.
Immediate postoperative 30° angled view showing the complete removal of polyps with a widened frontal sinus recess superiorly and widened ethmoid cavity in the mid portion. The middle turbinate is on the right, pushed against the septum. The lateral nasal wall is on the left.
Fungal ball in the right maxillary sinus.
Fungal debris being removed from the ethmoid complex. A suction device is seen in the right lower corner of the picture.
Allergic mucin, fungal debris, and polyps are shown after removal from the patient. The scale is in inches.
Coronal CT scan showing the postoperative view following removal of disease after significant disease recurred on both the right and left sides of the nasal cavity and sinuses; mild mucosal thickening of all involved sinuses is present, with some moderate thickening of the left maxillary sinus. All disease, even the lateral mucocele, was removed or drained endoscopically.
Two-week postoperative endoscopic picture showing polypoid thickening already in the ethmoid cavities while the patient was still on tapering steroids; on the left is the lateral nasal wall. The right shows the middle turbinate next to the septum.
A polypoid recurrence in the center of the ethmoid cavity. The septum is on the left.
Table 1. Causative Fungus Identified at UT Southwestern Medical Center
Fungus Children (n=44) Adults (n=107)
Bipolaris 21 (66%, 21/32) 40 (57%, 40/70)
Curvularia 7 (22%, 7/32) 12 (17%, 12/70)
Exserohilum 2 2
Alternaria 1 3
Aspergillus (niger/flavus) 0 9 (13%)
Acremonium 0 1
Chrysosporium 0 1
Helminthosporium 0 1
No Growth 2 21
No Data 12 16
Combination 1 Bipolaris/Curvularia 1 Aspergillus/Acremonium
Table 2. Facial Asymmetry Characteristics
Condition Children Adults
Presence of facial asymmetry (44 children, 107 adults studied) 15/36 (42%) (8 unknown)* 10/103 (10%) (4 unknown)*
Proptosis (obvious) with telecanthus, with/without malar flattening 8/15 7/10
Proptosis (measured, not obvious, £2 mm) 0/15 2/10
Telecanthus alone 6/15 1/10
Malar flattening alone 1/15 0/10
*Not all initial clinical records mention the presence or absence of facial asymmetry or vision problems.
Table.
Site Children (n=10) (25%, 10/40) Adults (n=23) (23%, 23/100)
Intracranial anterior cranial fossa 3 9
Middle cranial fossa 1 4
Posterior cranial fossa 2 2
Orbit 6 17
Pterygopalatine fossa 1 3
Nasopharynx 3 2
*Multiple sites were affected in some patients.
Table 4. Protocol for Immunotherapy in Allergic Fungal Sinusitis
Protocol
1. After successful surgical exenteration of sinuses and confirmation of diagnosis, perform allergy evaluation and testing (RAST or quantitative skin test) for typical panel of nonfungal antigens appropriate for the area. Test (RAST or quantitative skin test) for all relevant molds (fungi) available. Discuss treatment protocol with the patient and obtain informed consent.
2. Instruct the patient in avoidance measures for molds. Adjust pharmacotherapy as necessary.
3. Prepare a vial of all positive nonfungal antigens and a second vial of all positive fungal antigens. Perform a vial test with each.
4. Administer immunotherapy weekly, with dosage advancement as tolerated, placing 1 injection from each vial in a different arm. This allows for accurate recognition of the cause of any local reactions noted.
5. Observe the patient regularly and adjust dosage as necessary if local reactions or adverse changes in nasal signs/symptoms occur. Regularly examine the patient with endoscopy to detect reaccumulation of allergic mucin or reformation of polyps and to ensure that cleaning, medical management, etc, are carried out.
6. As dosage advancement permits (generally by second vial), antigens may be combined into 1 vial; continue for a 3- to 5-year regimen according to standard practice.
Reproduced from Mabry RL, 1998.
Table 5. Fungal Antigens in Current Testing and Treatment Protocol at the University of Texas Southwestern Medical Center at Dallas
Fungal Antigens in Approximate Relative Order of Local (Dallas, TX) Importance
Helminthosporium
Alternaria
Stemphyllium
Curvularia
Aspergillus
Epicoccum
Fusarium
Mucor
Pullularia
Cladosporium
Penicillium
Reproduced from Mabry RL, 1998.
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.