eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Allergy

Allergic Fungal Sinusitis: Treatment

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

Treatment

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.13

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.14,15 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. The antigens for which they test and treat are listed in Table 5. Table 4. Protocol for Immunotherapy in Allergic Fungal Sinusitis

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Table

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.

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

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Table

Fungal Antigens in Approximate Relative Order of Local (Dallas, TX) Importance

Helminthosporium

Alternaria

Stemphyllium

Curvularia

Aspergillus

Epicoccum

Fusarium

Mucor

Pullularia

Cladosporium

Penicillium

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.16 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.

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.

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.

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 (see Image 10). 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.

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 (see Images 11-13), 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.

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 (see Image 6, Image 14).

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.

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.

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.

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.17 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 eMedicine article Pediatric Sinusitis, Surgical Treatment).

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.

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.

Pharmacy Editor

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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