Allergic Fungal Sinusitis Treatment & Management

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. ^[24]

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. ^{[25, 26]} 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)

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

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. ^[27] 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.

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.

A retrospective study by Masterson et al indicated that for patients with allergic fungal rhinosinusitis, quality-of-life improvement following endoscopic sinus surgery is significantly greater than for patients with nonfungal chronic rhinosinusitis without nasal polyposis, at 9- and 12-month follow-up. Quality of life was evaluated via the 22-item Sino-Nasal Outcome Test (SNOT-22). ^[28]

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.

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.

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.

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.

(A prospective study by Tilak et al indicated that endoscopic endonasal access to lateral and superior frontal sinus pathology, including allergic fungal sinusitis (AFS), can safely and effectively be accomplished using the periorbital suspension technique. The approach is designed to address frontal sinus pathology that is too far lateral or superior to reach via traditional endoscopic transnasal methods. The investigators looked at 30 surgeries, including two for allergic fungal sinusitis (AFS), in which the periorbital suspension approach was used. Intraoperative or postoperative complications did not occur (follow-up time 11.7 mo), and all pathologies were successfully accessed. ^[29] )

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 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. ^[30]

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.

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. ^{[31, 32]} 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.

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. ^[33] 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 first image below, polyps as depicted in the second 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.

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.

A study by AlQahtani et al found that in patients with unilateral allergic fungal rhinosinusitis (AFRS), the risk of contralateral postoperative development of the condition was increased when, prior to endoscopic sinus surgery, the contralateral side was symptomatic and demonstrated signs of inflammation. Contralateral sinus involvement was decreased in patients in whom budesonide irrigation was used postoperatively. ^[34]

A literature review by Loftus et al found allergic fungal rhinosinusitis to be a top risk factor for revision endoscopic sinus surgery in patients who have undergone surgery for chronic rhinosinusitis with nasal polyposis. The investigators reported that allergic fungal rhinosinusitis was present in 28.7% of patients in whom revision was performed. ^[35]

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.