Recurrence of allergic fungal rhinosinusitis after endoscopic sinus surgery: A retrospective comparative study between nasal and oral steroids

Multidisciplinary consensus on a stepwise treatment algorithm for management of chronic rhinosinusitis with nasal polyps.

Post-operative care in FESS is an important aspect. Nasal saline irrigation and Nasal steroid spray are highly recommended worldwide in post-operative protocol after endoscopic sinus surgery. Hence patients compliance for both these procedures becomes a deciding factor for outcomes following FESS and there is not much evidence in literature regarding the same. The present study was conducted to evaluate the role of giving patients pictorial handouts regarding nasal saline irrigations and various positions of using nasal steroid spray in improving outcomes of FESS. It was a randomised control study.46post operative patients of FESS were randomised into two groups. Group A patients were verbally explained and practically demonstrated the technique of nasal saline irrigation and nasal steroid spray in the language best understood and by showing them the relevant images. Group B patients were also verbally explained as well as practically demonstrated the above mentioned procedure but were also given pictorial handouts (depicting in detail the positions of nasal saline irrigation and steroid spray} which were explained and handed over to them at the time of discharge. The patients were evaluated a 1st, 2nd 3rd and 4th post-operative week for compliance of both the procedures and its effect on post-operative cavity. In the present study there were 21 females versus 25 males. The average male: female ratio in group A was 1.3 versus 1 in group B. The mean age was 35.5652 ± 4.595 in group B versus 33.1739 ± 4.438 in group A. The average compliance over three weeks was 2.5765 ± 0.207 in Group B as compared to 1.4935 ± 0.27 in Group A. The t score for the difference in compliance between two groups was 15.2691. The two-tailed P value was less than 0.0001. The average Lund and Kennedy endoscopic appearance score for crusting was 1.75 ± 0.532, 1.217 ± 0.6, 0.696 ± 0.703 for Group A in post-operative follow up during week 1, 2 and 3 respectively as compared to 1.45 ± 0.59, 0.304 ± 0.47, 0.826 ± 0.49 for Group B. The P value was < 0.05 for the difference in both groups for all three weeks. The average Lund and Kennedy score for edema and other parameters has been enumerated in Table 1. 11/23 followed correct method for nasal saline irrigation in Group A as compared to 20/23 in Group B. 18/23 used nasal steroidal spray in all positions compared to only 9/23 in Group A. 3/23 in group B had polypoidal mucosa at frontal recess area at 1month post-operative as compared to 16/23. Overall their was a negative correlation between the compliance of nasal saline irrigation with edema, crusting and discharge. The respective R score was -0.5311, -0.25296 and -0.19889 respectively. The pictorial handouts definitely improved compliance and hence outcomes in our study. We recommend this practice in routine to all our fellow rhinologists.

Background Topical nasal steroids are commonly prescribed to patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) following endoscopic sinus surgery (ESS). They are found to be effective in improving symptoms and quality of life as well as reducing the incidence of nasal polyps recurrence. Objective We sought to determine whether a higher concentration of topical nasal steroid spray is more effective than the standard nasal steroid spray in controlling symptoms and preventing recurrence of polyps in patients with CRSwNP who underwent ESS. Method A double-blind randomized controlled trial was performed on patients with CRSwNP after ESS. Patients were randomized into 2 treatment groups: one received topical nasal dexamethasone 0.032% and the other, fluticasone proprionate. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy nasal endoscopy scores were measured at the initiation of topical nasal steroid treatment and then at approximately 4-, 8-, and 12-week intervals. Results Thirty-nine patients were enrolled in the study. Eighteen patients continued using the medications prescribed to them for the duration of the study. There were 8 patients in the dexamethasone group and 10 patients in the fluticasone group. Both groups saw significant improvements in postoperative SNOT-22 and Lund-Kenney scores over time. There was no significant difference in improvement between the groups. Conclusion There is no significant increased benefit in using a higher dose nasal steroid spray compared to the standard dose nasal steroid spray after ESS.

Introduction: Otitis media with effusion (OME) is defined as effusion in the middle ear without signs and symptoms of an acute infection. Objectives:To evaluate the efficacy of nasal steroids in OME in children by compared with oral steroids and with nasal saline spray. Patients and Methods: This study included 60 children with bilateral OME. The children were divided into three equal groups; group A, 20 children received mometasone furoate nasal spray. In group B, 20 children received oral prednisolone. In group C, 20 child received hypertonic sea water nasal spray. Clinical follow-up was done once per week for 4 weeks, at the end of treatment, and then monthly for 3 months. Otoscopic examination, audiological evaluation was done before treatment for each group and repeated at 3,6 months after treatment. Results: A highly significant difference between systemic or topical nasal steroid and hypertonic sea-water nasal spray was detected regarding symptoms improvement, clinical examination, adenoids hypertrophy and hearing condition. The difference between systemic and topical steroid was statistically insignificant. Conclusion: Nasal steroid spray is an effective treatment for OME, with a result similar to systemic steroid but without the hazard of corticosteroids.

Allergic fungal rhino sinusitis (AFRS) is a non-invasive fungal sinusitis resulting from an allergic and immunologic response to the presence of extramucosal fungal hyphae in the sinuses. Defined largely by the presence of allergic fungal mucin, which is a thick, tenacious, and eosinophilic secretion with characteristic histologic findings. To present a case series on the variable presentations in patients diagnosed with AFRS. A retrospective study of 10 cases that presented to Rajiv Gandhi Government General Hospital ENT outpatient department with allergic fungal rhinosinusitis confirmed by diagnostic nasal endoscopy and CT scan who were managed successfully by endoscopic sinus surgery. In our study, out of 10 cases, nine patients had unilateral symptoms, only one patient has bilateral symptoms. Most common presentation was headache, facial pain, nasal obstruction, and nasal discharge. Some patients had variable presentations such as proptosis, oroantral fistula, blurring of vision, watering of eye, and unilateral frontal headache. On diagnostic nasal endoscopy, two patients had nasal polyposis. Complete disease clearance was achieved in nine cases by functional endoscopic sinus surgery. Patients were started on topical and oral corticosteroids, pre/postoperatively. On follow-up, only one patient had recurrence. Preventing and treating the condition, as well as its spread and complications, are greatly aided by early detection and management of AFRS. The key to enhancing the result is surgical intervention (endoscopic sinus surgery) and medical therapy (corticosteroids). Antifungals have limited role in treatment of AFRS. Longstanding unilateral Sinusitis should always raise suspicious of AFRS.

Expanding the evidence base for the medical treatment of nasal polyposis

BackgroundPatients with chronic rhinosinusitis (CRS) refractory to medical management often require endoscopic sinus surgery (ESS). Oral corticosteroids (OCSs) are frequently prescribed postoperatively, but the evidence of their efficacy is limited.ObjectiveThe purpose of this study is to evaluate the efficacy of OCS use in patients with CRS following ESS.MethodsA systematic search was performed to identify studies examining the use of OCSs in patients undergoing ESS for CRS. The primary outcomes were sinonasal outcome test (SNOT) and Lund-Kennedy (LK) endoscopic scores. Secondary outcomes were visual analog scale (VAS) scores. Meta-analysis was conducted using a fixed effects model with a heterogeneity test via the I2 statistic.ResultsThe search yielded 1899 articles, and 22 were included in the qualitative analysis, 14 of which were randomized controlled trials with 793 total patients. OCS use differed based on type, dosage, and duration. Studies included in meta-analysis did not show a significant difference in SNOT (Standardized Mean Difference [SMD] -0.03, Confidence Interval [CI] -0.47-0.40, I2 0%), LK (SMD -0.20 CI -0.57-0.17 I2 58%), or VAS (SMD 0.19 CI -0.25-0.63 I2 54%) scores between steroid and non-steroid groups. Two studies that assessed OCSs in the allergic fungal rhinosinusitis (AFRS) subtype of CRS showed significant improvement in outcomes. Two additional studies examined OCS versus itraconazole in AFRS, with both groups showing improvement but neither one with greater significance.ConclusionThis study showed no significant difference in SNOT, LK, or VAS scores in patients with CRS who received OCSs following ESS. Given the limited number of studies in the analysis, further investigations are warranted before making recommendations.

Fungal sinusitis is broadly classified into invasive and non invasive types. Invasive type presents with fungal hyphae within the mucosa, submucosa, bone, or blood vessels of the paranasal sinuses and includes Acute Invasive Fungal Sinusitis, Acute Fulminant, Chronic Invasive Fungal Sinusitis, Chronic Granulomatous Fungal Sinusitis. Invasive forms of fungal rhinosinusitis are rare and confined to groups of patients who are immunocompromised (Key in Fungal rhinosinusitis). Noninvasive type shows absence of fungal hyphae within the mucosa paranasal sinuses. It includes Allergic Fungal rhinosinusitis, Fungus Ball (fungus mycetoma). The study was performed on a total of 30 patients, in Department of Otorhinolaryngology, at our hospital after getting approved by theInstituitional Human Ethical Committee. We selected 30 patients diagnosed with allergic fungal sinusitis and studied their varied clinical presentations and treatment for a period of 1year. It was a prospective case series type of study. Patients who presented with symptoms of allergic fungal rhinosinusitis were included. Patients who were referred with complaints of proptosis, diplopia were also included to rule out allergic fungal rhinosinusitis and its complications. Patients diagnosed with chronic granulomatous infection of nose and invasive fungal sinusitis were excluded. Evaluation of patients involved a detailed case history followed by clinical examination and radiologic investigation. After getting proper consent, we did a study of 30 patients who presented to our outpatient department with complaints of sinusitis. Our study included 12 male and 18 female patients. Among these patients, all of them had complaints of frequent allergic rhinosinusitis, nose block, facial heaviness. 12 among them had olfactory disturbances, reduced perception of smell. 4 patients presented with visual disturbances and proptosis which subsided after endoscopic sinus surgery was done.24 among these patients had presence of allergic fungal mucin in their nasal secretions and 10 patients had history of associated atopy and asthma and elevated Ig E levels. And 20 of these patients showed high eosinophil counts. All these patients in our case series were under the age group 22-70years. These patients were treated with a course of nasal sprays and preoperative steroids in case of extensive polyposis and were taken up for functional endoscopic sinus surgery. Polypoidal mucosa was removed, diseased tissue was cleared, sinus blockage was released and fungal mucin/tissue bits were sent for histopathological analysis, KOH mount and fungal culture. This study included a series of cases which showed a wide range of the various clinical presentations that occur in cases of allergic fungal rhinosinusitis, its diagnosis and treatment. The advantage of this study was we had analyzed a good number of cases with varied presentations. Since AFRS is closely related with EMRS, CRS a proper clinical, radiological and immunological evaluation of the cases help in knowing the correct diagnosis and treatment.

Oral and Nasal Steroids for Nasal Polyps

BACKGROUND AND OBJECTIVES:Endoscopic sinus surgery (ESS), markedly improved with the introduction of new preoperative imaging techniques, intraoperative visualization tools, and the use of surgical navigation systems. In this retrospective study we evaluated the usefulness of CT-guided endscopic sinus surgery and studied its advantages over conventional endscopic sinus surgery.METHODS:We retrospectively reviewed the records of 60 randomly chosen patients with chronic rhinosinusitis (CRS) and moderate-to-severe sinonasal polyposis, undergoing endoscopic sinus surgery with surgical navigation (n=30) and without navigation (n=30). Data on the operative note, time of surgery, complications, and recurrence rate were collected and analyzed.RESULTS:Of the 60 patients, 40 (66.7%) were diagnosed with CRS and 20 (33.3%) had allergic fungal sinusitis. Primary surgery was performed in 37 (61.7%) and revision surgery was performed in 23 (38.3%) cases. The computer-aided surgery (CAS) group included 28 (93.3%) patients with extensive disease and 12 (40%) with bone erosions, with intraorbital or extradural extension, while the non-CAS group included 24 (80%) patients with extensive disease and seven (23.3%) with bone erosions, with intraorbital or extradural extension. The average operative time was approximately 13 minutes greater in the navigation group, with significant improvement in the recurrence rate (n=11, 36.7% in the non-CAS group; n=5, 16.7% in the CAS group), and intraoperative complications were fewer in the CAS group (two exposures of orbital fat in the non-CAS group; no complications in the CAS group).CONCLUSION:Computer navigational systems appear to serve as a valuable adjunct in preoperative planning and safe intraoperative dissection.

Allergic fungal rhinosinusitis (AFRS) is a subset of polypoid chronic rhinosinusitis that is characterized by the presence of eosinophilic mucin with fungal hyphae within the sinuses and a Type I hypersensitivity to fungi. The treatment of AFRS usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal medical regimen is still controversial. Hence, the purpose of this article is to provide an evidence-based approach for the medical management of AFRS. A systemic review of the literature on the medical management of AFRS was performed using Medline, EMBASE, and Cochrane Review Databases up to March 15, 2013. The inclusion criteria were as follows: patients >18 years old; AFRS as defined by Bent and Kuhn; post-sinus surgery; studies with a clearly defined end point to evaluate the effectiveness of medical therapy in postoperative AFRS patients. This review identified and assessed 6 medical modalities for AFRS in the literature: oral steroids; topical steroids; oral antifungals; topical antifungals; immunotherapy; and leukotriene modulators. Based on available evidence in the literature, postoperative systemic and standard topical nasal steroids are recommended in the medical management of AFRS. Nonstandard topical nasal steroids, oral antifungals, and immunotherapy are options in cases of refractory AFRS. No recommendations can be provided for topical antifungals and leukotriene modulators due to insufficient clinical research reported in the literature.

Advances in upper airway diseases and allergen immunotherapy

Allergic fungal rhinosinusitis (AFRS) is characterized by higher revision endoscopic sinus surgery (ESS) rates and unique radiographic features when compared to chronic rhinosinusitis with nasal polyposis (CRSwNP) or chronic rhinosinusitis without nasal polyposis (CRSsNP). We hypothesized that an increased frequency of concha bullosa in AFRS or other radiographic nuances might allow for accumulation of allergic mucin and contribute to increased ESS revision rates. A retrospective cohort study was performed. Patient diagnosis (AFRS, CRSwNP, and CRSsNP), basic demographics, and prior ESS rates were collected. A total of 210 consecutive patients were included (AFRS = 70, CRSwNP = 70, and CRSsNP = 70). Pediatric AFRS patients had more unilateral disease (38.1% vs 4.4%; P = .007) and anterior ethmoid skull base erosion (23.8% vs 6.7%; P = .047) than adult AFRS patients. AFRS patients were more likely to be younger (24.9 ± 10.1 years vs 45.6 ± 14.4 years vs 48.7 ± 18.2 years; P < .001), African American (70% vs 14.3% vs 11.4%; P < .001), and have undergone prior ESS (54.3% vs 45.7% vs 31.4%; P = .02) than CRSwNP or CRSsNP patients. Concha bullosa were more prevalent in AFRS patients than CRSwNP or CRSsNP patients across the population (42.9%, 18.6%, and 14.3%; P < .001) and in the setting of no previous surgery (53.1%, 31.6%, and 16.7%; P < .001). In this cohort, pediatric AFRS patients had more unilateral disease and anterior ethmoid skull base erosion. Concha bullosa prevalence was significantly higher in AFRS as compared to those with CRSwNP or CRSsNP, despite prior ESS. Surgeons should consider concha bullosa as a potential anatomical subsite to harbor recurrent or residual disease.

To conduct a systematic review and network meta-analysis to evaluate the safety and efficacy of intrapolyp steroid injection compared with oral steroids, nasal steroid wash, nasal steroid spray, and a control group in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). PubMed, Scopus, Web of Science, Embase, and CENTRAL. Both randomized and non-randomized clinical trials were included. For risk of bias assessment, we used the RoB-2 and ROBINS-I tools. Our outcomes focused on safety and efficacy, including rates of visual disturbance and bleeding, as well as improvements in nasal polyps evaluated through three domains: endoscopic, radiologic, and patient-reported assessments. Safety data were pooled as events (%), while efficacy data were pooled as mean difference (MD) or standardized mean difference (SMD). Eight clinical trials involving 579 patients were analyzed. The pooled analyses showed low event rates for visual disturbances (event rate = 0.64%, 95% CI [0.00%, 2.23%]) and bleeding (event rate = 0.61%, 95% CI [0.00%, 2.25%]). Additionally, intrapolyp steroid injections were found to be comparable with oral steroids, with no statistically significant differences. Moreover, intrapolyp steroid injections demonstrated some superiority over nasal sprays, nasal washes, and the control group. This network meta-analysis confirms that intrapolyp steroid injections have a favorable safety and efficacy profile as a viable management option for CRSwNP. The injections showed comparable efficacy with oral steroids and demonstrated certain advantages over other treatments, such as nasal sprays and washes. Further research with larger sample sizes and standardized protocols are needed. Laryngoscope, 135:1872-1883, 2025.

Central compartment atopic disease (CCAD) is a variant of chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) characterized by polypoid changes of the superior nasal septum, middle (MT), and/or superior turbinates (ST). This study evaluates surgical outcomes in patients with CCAD compared with other CRSwNP subtypes. Retrospective analysis was performed at Emory University from May 2012 to November 2019. Patients undergoing primary endoscopic sinus surgery (ESS) for CCAD, aspirin-exacerbated respiratory disease (AERD), allergic fungal rhinosinusitis (AFRS), and CRSwNP not otherwise specified (CRSwNP NOS) were included consecutively, beginning with the earliest date of CCAD patient. Outcome measures included polyp recurrence, revision ESS, oral steroid use, and oral antibiotic use. Pearson chi-square and univariate analysis of variance (ANOVA) were performed for group comparisons. Data was collected for 132 patients (CCAD=38, AERD=20, AFRS=37, CRSwNP NOS=37; 58 females, mean age 42.9 years [range, 13-85 years]). CCAD patients demonstrated polyp recurrence less frequently than expected, whereas AFRS patients had polyp recurrence more frequently than expected (p=0.003; phi 0.32). CCAD patients underwent revision ESS less frequently than expected; AFRS and CRSwNP NOS underwent revision ESS more frequently than expected (p=0.03; phi 0.26). CRSwNP NOS patients received more total antibiotic courses than those with CCAD (p=0.01; eta-squared 0.09) and more courses of antibiotics per month than those with AFRS (p=0.03; eta-squared 0.07). There was no significant difference in follow-up measures across groups (number of visits, total months, or visits per month). Rates of polyp recurrence and revision ESS were significantly lower in CCAD patients compared with patients with other CRSwNP subtypes, suggesting durable benefit of ESS and postoperative medical therapy in CCAD patients.