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Allergic Fungal Sinusitis Workup

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

Laboratory Studies

See the list below:

  • Total immunoglobulin E
    • Total IgE values generally are elevated in allergic fungal sinusitis (AFS), often to more than 1000 U/mL (normal values are < 50 U/mL).
    • Total IgE level traditionally has been used to monitor the clinical activity of allergic bronchopulmonary fungal disease.
    • On the basis of similar IgE behavior associated with recurrence of allergic fungal sinusitis (AFS), total IgE levels have been proposed as a useful indicator of allergic fungal sinusitis (AFS) clinical activity.
  • Immunologic testing for allergens
    • RAST versus skin testing
      • Patients with allergic fungal sinusitis (AFS) generally demonstrate positive skin tests and in vitro (RAST) responses to fungal and nonfungal antigens. Manning et al, who compared 16 patients with histologically confirmed allergic fungal sinusitis (AFS) with a control group of patients with chronic rhinosinusitis, first demonstrated the sensitivity of RAST. Levels of fungal-specific IgE were uniformly elevated in all patients with allergic fungal sinusitis (AFS) and corresponded to the results of fungal cultures. In contrast, levels of fungal-specific IgE were not elevated within the control group. Moreover, patients with allergic fungal sinusitis (AFS) appear to demonstrate a broad sensitivity to a number of fungal and nonfungal antigens. Mabry et al have reported their experience, which indicates that patients with allergic fungal sinusitis (AFS) are allergic to multiple fungal antigens and to many typical nonfungal antigens.
      • Preliminary information suggests that methods of quantitative skin testing (in vivo) may provide even greater sensitivity ratings than RAST in patients with allergic fungal sinusitis (AFS). RAST traditionally has been considered less sensitive than skin testing during the investigation of atopy involving fungi. This has been attributed to technical problems, such as difficulty in binding the mold antigen to the carrier substrate.
      • To study the validity of this concept, Mabry et al prospectively evaluated 10 patients with allergic fungal sinusitis (AFS) for sensitivity to 11 pertinent fungi by both RAST and dilutional intradermal testing. A predictable correlation between RAST and skin test scores was observed in many, but not all, patients. Most often, this disparity was in the form of greater sensitivity indicated by skin testing than by RAST, sometimes differing by as many as 3 classes.
      • The lack of concordance was not confined to testing for fungi cultured from the sinuses, nor was it more or less pronounced in the case of dematiaceous fungi. The most likely causes for the disparity were thought to involve subtle differences in antigens used in skin test material as compared to RAST standards. Additionally, skin testing allowed observation of delayed and late-phase reactions, a measure not possible by specific IgE testing with RAST. This study appears to emphasize the importance of both skin testing and specific IgE testing via RAST in initial evaluation of patients in whom allergic fungal sinusitis (AFS) is suspected.
    • Nonspecific allergy testing
      • Gell and Coombs type I hypersensitivity in patients with allergic fungal sinusitis (AFS) can be demonstrated by elevation of serum total and fungal-specific IgE and by positive skin test results for fungal and nonfungal antigens. However, this reaction does not appear to be fungal specific.
      • Sensitivity to numerous fungi has been indicated both by in vitro (RAST) and in vivo methods (skin testing), although generally, only a single fungus is isolated by culture of corresponding allergic fungal mucin. This previously has been thought to represent either a common fungal epitope or a genetic predisposition toward fungal allergy in allergic fungal sinusitis (AFS).
      • Recent work by Chrzanowski et al identified the presence of an 18-kd protein in allergic mucin obtained from patients with allergic fungal sinusitis (AFS), which may represent such a pan-antigen.
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Imaging Studies

See the list below:

  • Computed tomography [16]
    • Accumulation of allergic fungal mucin eventually leads to the increasingly well-recognized radiographic findings characteristic of allergic fungal sinusitis (AFS). Heterogeneous areas of signal intensity within paranasal sinuses filled with allergic fungal mucin frequently are identified on CT scans, 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 typical unilateral appeara 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.
      See the list below:
      • Although these findings are not specific for allergic fungal sinusitis (AFS), they remain relatively characteristic of the disease and may provide preoperative information supportive of a diagnosis of allergic fungal sinusitis (AFS). This characteristic, which is best identified using soft-tissue algorithms on CT scan, has been the focus of some interest.
      • An initial theory proposed that the role of hemosiderin occurring within inspissated mucin is responsible for the areas of increased signal intensity. This was disputed by Zinreich et al, who were unable to identify increased hemosiderin within typical allergic fungal mucin. Current evidence points to the presence of accumulations of heavy metals (eg, iron, manganese) and calcium salt precipitation within inspissated allergic fungal mucin as the most likely causes of these radiographic findings.[17]
    • Expansion, remodeling, or thinning of involved sinus walls is common in allergic fungal sinusitis (AFS) and is thought to be caused by the expansile nature of the accumulating mucin. Areas of high attenuation are found within the expanded paranasal sinuses in all patients. Similar radiographic findings can be caused by rare osteoid/chondroid matrix-producing sinonasal sarcomas or meningiomas.
    • Bony erosion of the sinus walls and extension into adjacent cavities have been mentioned in many reports, usually focusing on intracranial extension, as depicted in the 1st image above. In most series, a rate of approximately 20% bony erosion with extension into surrounding vital cavities is reported.
      • A recent review at UT Southwestern focusing on patterns of bony erosion in all the authors' patients found a 20% rate of erosion with extension. Sites of extension included the nasopharynx and pterygomaxillary space and intracranial and intraorbital areas.
      • A statistically significant association was identified between expansion of paranasal sinuses involved with disease and the presence of bone erosion.
      • The ethmoid sinus was the most commonly involved sinus, while the adjacent lamina papyracea was the most common bone to exhibit demineralization, as depicted in the image below. Extension of allergic fungal sinusitis (AFS) beyond the confines of the paranasal sinuses most commonly occurred into the orbit, followed by the anterior, middle, and posterior cranial fossae, respectively.
        Coronal CT scan showing typical unilateral appeara 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.
      • When evaluating children and adults in the authors' population separately, no difference was observed in the amount or location of bony erosion with extension, as depicted in the Table below.
      • Despite the sometimes-remarkable extension into adjacent anatomic spaces, no cases of histologic invasion of fungus into the adjacent barriers of the orbital periosteum or dura of the brain were identified on histologic review.
    • Although bilateral in 51% of cases reviewed in a large interinstitutional trial of 45 patients, allergic fungal sinusitis (AFS) caused asymmetric involvement of the paranasal sinuses in 78% of patients. Asymmetrical involvement actually is more pronounced in children. In a review of 151 children and adults, the author and colleagues demonstrated that children have more asymmetrical involvement than adults (88% vs 58%) and have a much greater incidence of unilateral disease on presentation than adults (70% vs 37%). Adults in this study presented most often with bilateral disease, but as in the interinstitutional study, asymmetrical disease was seen more often.
    • Table 3. Sites of Extension of Allergic Fungal Sinusitis From the Paranasal Sinuses*

      Table. (Open Table in a new window)

      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.
  • Magnetic resonance imaging [16]
    • MRI also can provide information useful in preoperative identification of allergic fungal mucin, but it usually is not necessary when making the diagnosis unless the disease has extended into the intracranial cavity or confusion exists with the diagnosis. Som and Curtin have pointed out that protein concentrations exceeding 28% cause a decreased signal on T1- and T2-weighted MRI images because of protein cross-linking and slower macromolecular motion. This effect is more pronounced on T2-weighted images because of prolonged magnetic field relaxation times. The high protein and low water concentration of allergic fungal mucin, coupled with the high water content within surrounding edematous paranasal sinus mucosa, gives rise to rather specific MRI characteristics, as depicted in the image below.
      Coronal MRI showing expansion of the sinuses with 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.
    • In a series of 10 patients with allergic fungal sinusitis (AFS), Manning et al demonstrated that hypointense central T1 signal, central T2 signal void, and the presence of increased peripheral T1/T2 enhancement were highly specific for allergic fungal sinusitis (AFS) when compared to other forms of fungal sinusitis (invasive fungal sinusitis, fungal ball) and mucocele. On MRI, the hypointense signal looks black and can be mistaken for absence of disease in the paranasal sinuses because a black signal in the sinuses on CT scan indicates the absence of disease. Compare the two images below. The combined CT scan and MRI findings provided a radiographic appearance that was highly specific for allergic fungal sinusitis (AFS).
      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 MRI showing expansion of the sinuses with 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.
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Histologic Findings

Allergic fungal mucin, as depicted in the images below normally is first encountered at surgery. Therefore, recognition of its presence is the initial step in establishing an accurate diagnosis of allergic fungal sinusitis (AFS). Realizing that mucin, rather than paranasal sinus mucosa, demonstrates the histologic appearance consistent with allergic fungal sinusitis (AFS) is important. Examination of mucosa and polyps obtained from involved paranasal sinuses reveals findings consistent with the inflammation of a chronic inflammatory process and should be performed to exclude fungal invasion. Once mucin is collected, culture and pathologic examination are undertaken.

Left middle meatus with suctioning of thick allerg 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 suct The viscosity of a thick allergic mucin being suctioned from the nasal cavity and vestibule in a patient with allergic fungal sinusitis.

Initially described by Millar and Lamb and Katzenstein et al, histologic examination of allergic mucin reveals a constellation of characteristic findings.[18] Branching noninvasive fungal hyphae are identified within sheets of eosinophils and elongated eosinophilic bodies (Charcot-Leyden crystals), which represent the product of eosinophilic degradation. Use of various histologic staining techniques helps to identify the variety of components within allergic fungal mucin. Hematoxylin and eosin (H&E) staining accentuates the mucin and cellular components of allergic fungal mucin. Using this stain, background mucin often takes on a chondroid appearance, while eosinophils and Charcot-Leyden crystals are heavily stained and become easily detectable.

Fungi fail to stain using this technique and therefore may be difficult to identify. The presence of fungi may be implicated on H&E stain by the resulting negative image against an otherwise stained background. However, fungal hyphae and elements are often rare, scattered, and fragmented within allergic mucin, rendering identification difficult unless specific histologic stains are used. Fungal elements are recognized for a unique ability to absorb silver. This property is the basis for various silver stains, such as the Grocott-Gomori methenamine silver (GMS) stain, which turns fungi black or dark brown. The use of a fungal stain complements the findings of initial H&E stain and is extremely important in the identification of fungi.

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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 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].

 
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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.
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