Cases Of Allergic Fungal Sinusitis Research Articles

Visual loss in the setting of allergic fungal sinusitis: pathophysiology and outcome

To hypothesise the probable pathophysiological mechanism responsible for visual loss in allergic fungal sinusitis, other than direct compression. Retrospective, non-randomised case series. Out of 274 cases of allergic fungal sinusitis, four cases with sudden visual loss were enrolled into the study. The fourth case had visual loss on the contralateral side to bony erosion of the lateral wall of the sphenoid sinus. All four cases were evaluated with fungal smear, immunoglobulin (Ig) E titres, visual evoked potentials, non-contrast computed tomography and magnetic resonance imaging of the paranasal sinuses, and fundus examination. They then underwent endoscopic sinus debridement followed by intravenous methylprednisolone. Improvement in vision. All four cases experienced an improvement in vision: full recovery in three cases and partial improvement in one case. In view of the operative, radiological and laboratory findings for case four, with the suggestion of a hyperimmune response to fungal antigens (in the form of raised IgE titre and positive fungal serology), we suggest that a local immunological reaction to fungal antigens might be responsible for the observed visual loss in cases of allergic fungal sinusitis, in addition to mechanical compression of the optic nerve.

Presentation and management of allergic fungal sinusitis.

To assess the presentation of allergic fungal sinusitis and describe the line of management in our setup. Descriptive study. Study was conducted in Otorhinolaryngology Department, Dow Medical College and Civil Hospital, Karachi, from January 2004 to January 2005. Culture and sensitivity / fungal stain proven 20 cases of allergic fungal sinusitis were selected for the study, irrespective of age and gender. Data including age, gender, socioeconomic status, signs, symptoms, laboratory findings (especially Immunoglobulin E and eosinophil count) and imaging studies (Computed Tomography and /or Magnetic Resonance Imaging) were noted for the study. Pre and postoperative medical treatment, surgery performed, follow-up; residual/recurrence disease and revised surgery performed were also recorded. In this series, allergic fungal sinusitis was a disease of younger age group with an average age of 20.75 years with male dominance (70%). Poor socioeconomic status (80%), allergic rhinitis (100%) and nasal polyposis (100%) were important associated factors. Nasal obstruction (100%), nasal discharge (90%), postnasal drip (90%) and unilateral nasal and paranasal sinuses involvement (60%) were the commonest presenting features. Aspergillus (60%) was the most common etiological agent. In all cases (100%), increased eosinophil count and IgE levels were present. Orbital (20%) and intracranial (10%) involvement were also seen. Surgical management was preferred in all cases. Functional endoscopic sinus surgery in 90% cases and lateral rhinotomy in 10% cases were performed. Recurrence / residual disease was seen in 20% cases. In this series, allergic fungal sinusitis was seen in immunocompetent, young males, belonging to poor socioeconomic status, suffering from allergic rhinitis and nasal polyposis, presenting with nasal obstruction, nasal discharge and postnasal drip. Functional endoscopic sinus surgery was the most important problem solving procedure while lateral rhinotomy was reserved for extensive disease.

Concomitant Histopathological Findings of Allergic Fungal Sinusitis and Fungal Ball in the Same Sinus: A Rare Case Report

BACKGROUND: Allergic fungal sinusitis (AFS) and fungal ball (mycetoma) are two forms of noninvasive fungal sinusitis distinct in their clinical presentations, histopathologic features, treatment modalities, and prognoses. We report an unusual case where histopathological findings of both entities were found in the same sinus. CASE: A 63-year-old immunocompetent man with a history of allergic rhinitis, asthma and chronic rhinosinusitis (CRS) was referred to our clinic for worsening of asthma and sinonasal symptoms one year after undergoing maxillary sinus surgery. Laboratory investigations revealed peripheral eosinophilia (1300/μL) and a markedly elevated total IgE level (5469 kU/L; normal value <165 kU/L). Skin prick test was positive to A. fumigatus. The possibility of allergic bronchopulmonary aspergillosis was excluded with a normal CT of the chest. Sinus CT showed extensive mucosal changes of CRS; additionally, there was opacification associated with areas of calcification in the right maxillary sinus. At endoscopic sinus surgery, a large fungal ball embedded in thick mucus was recovered from the sinus. GMS staining showed dense branching fungal hyphae within the fungal mass and rare hyphal elements within the mucus. H&E staining revealed abundant clusters of eosinophils, consistent with allergic mucin. Mucosal biopsy demonstrated eosinophilic inflammation without fungal invasion. Cultures were negative. Systemic and topical steroids were initiated to reduce the eosinophilic inflammatory response and prevent disease recurrence. CONCLUSIONS: This is an unusual case of AFS and fungal ball coexistence in the same sinus, illustrating the importance of considering AFS as a diagnostic possibility in the presence of chronic rhinosinusitis associated with IgE-mediated hypersensitivity to fungi.

Allergic fungal sinusitis presenting as a paranasal sinus tumor.

We present a case of allergic fungal sinusitis (AFB) in a 20-year old man with few months' history of bilateral nasal obstruction and discharge with unilateral proptosis that underwent maxillary antrostomy due to the mass in paranasal sinuses. Histological examination of tissue showed branching fungal hyphae interspersed with allergic mucin without fungal invasion to soft tissue. The patient received local steroid for 4 months and had no problem during follow up. Fungal culture was performed and Bipolaris fungus grew. Although most dematiaceous fungal infections occur in immunocompetent patients, the incorrect diagnosis and insufficient treatment may be life threatening.

Sinusite fongique allergique et aspergillose bronchopulmonaire allergique: Association fortuite ou entité nosologique rhinobronchique ?

The identification of allergic fungal sinusitis (AFS) is much more recent than that of allergic broncho-pulmonary aspergillosis (ABPA) and may still be incomplete and controversial. Their association has been only rarely reported in the literature. Is it a matter of a fortuitous association or of a well defined and/or new nosological rhino-bronchial entity?A retrospective study was undertaken from a series of 10 cases of AFS with 4 cases associated with ABPA and fulfilling all the diagnostic criteria described in the literature.The association of AFS and ABPA may be concomitant (2 cases) or not (2 cases) with a possible time lag of several years between the onset of naso-sinal and broncho-pulmonary disease, even after recovery from the original episode. Treatment comprising steroids, endoscopic surgery (4 cases) combined with anti-fungal drugs (2 cases), led to resolution (2 cases), a considerable improvement (1 case) and therapeutic failure in 1 case (follow up longer than 4 years in all cases).The association, concomitant or remote in time, of AFS and ABPA emphasises the unity of the upper and lower airways as well as the pathophysiological relationship between these two fungal respiratory diseases. The prevalence of this association remains low and the treatment is not standardised.

Ethnic and Gender Differences in Bone Erosion in Allergic Fungal Sinusitis

Erosion of the bony sinus walls in allergic fungal sinusitis (AFS) is an established phenomenon. Reports of the incidence of bone erosion in AFS vary widely, and definitions of bone erosion lack uniformity. Differences in bone erosion among ethnic and gender groups have not been examined previously in the literature. At our institution we reviewed 47 cases of AFS for ethnic and gender differences in presentation and presence of bone erosion. Caucasians presented at a mean 12 years later than African-Americans (p = 0.002); however, this difference was largely carried by Caucasian females. African-Americans presented with a greater incidence of bone erosion than Caucasians (p = 0.028). In addition, there are statistically significant differences in the individual paranasal sinuses affected by bone erosion in AFS. We examine the potential implications of ethnic and gender differences in presentation and bone erosion in AFS.

Allergic fungal sinusitis: Can we predict the recurrence?

The goal of the present study was to find out if recurrence can be predicted in cases of allergic fungal sinusitis. We also studied the influence of postoperative corticosteroid therapy on recurrence following surgery. This study was conducted at the ENT Department of Al Nahdha Hospital, which is a tertiary referral and teaching hospital in Muscat, Sultanate of Oman. The study is a retrospective analysis of 32 cases of allergic fungal sinusitis. Age, sex, extent of disease, and preoperative serum IgE levels were compared in patients who had recurrence with those who did not. We also studied the incidence, onset, and severity of recurrence in patients who received systemic corticosteroid as postoperative therapy and compared these values to those who received nasal corticosteroid spray only. No statistically significant difference was noted in the parameters of age, sex, extent of disease, and preoperative serum IgE levels when these values were compared in the group of patients who had recurrence (8 patients) with the group of patients who did not (32 patients). No statistically significant difference was found in the incidence of recurrence in patients in whom systemic corticosteroids were used postoperatively (17 patients) compared with patients who used nasal corticosteroid spray only (15 patients). However, when the patient had a recurrence, when it occurred it was earlier and more severe in patients who used nasal corticosteroid spray only (4 patients). At the present time, it is not possible to predict recurrence using parameters of age, sex, extent of disease, and serum IgE levels. Larger number of patients preferably in a prospective multicenter meta study are required to address this issue. Though use of systemic corticosteroid does not decrease the incidence of recurrence, it may delay the onset of recurrence and decrease the severity of recurrence.

La Sinusite Fongique Allergique (SFA): A propos de 10 cas

Diagnosis, nosological individualization, and treatment of allergic fungal sinusitis remain difficult and controversial despite the increasing number of publications. We present ten cases of allergic fungal sinusitis and review the literature to highlight the main clinical, radiological, biological, immunoallergological, mycological, and therapeutics features. This retrospective study included ten patients (six men and four women, mean age 45 years) with allergic fungal sinusitis diagnosed on the basis of all diagnostic criteria reported in the literature. Six patients had isolated allergic fungal sinusitis which was associated with allergic bronchopulmonary aspergillosis in the four others. Treatment combined endoscopic sinus surgery and corticosteroids, which provided good results in six patients and average results in three. Treatment failure was observed in one patient. As in the case of allergic bronchopulmonary aspergillosis, a set of clinical, radiological, histopathological, immunoallergological and mycological criteria is necessary for precise diagnosis and to avoid fungal drift. The most appropriate endoscopic sinus surgery and the best corticosteroid regimen remain to be determined.

Fungal sinusitis: histologic spectrum and correlation with culture

Fungi are important etiologic agents of sinusitis. However, features of fungal sinusitis including the histologic spectrum, diagnostic mishaps, incidence, and fungal types have not been systematically studied. From 1996 through 2001, a total of 788 surgical pathology sinus specimens from 384 cases was retrieved. Fungal sinusitis was diagnosed in 58 specimens (7%) from 47 cases (12%). Four histologic categories of fungal sinusitis were identified: (1) allergic fungal sinusitis in 34 cases (copious mucin, abundant eosinophils, Charcot-Leyden crystals (so-called allergic mucin), with rare noninvasive fungal hyphae); (2) mycetoma/fungus ball in 11 cases (tightly packed fungal hyphae without allergic mucin or tissue invasion); (3) chronic invasive fungal sinusitis in 1 case (tissue granulomas with fungal hyphae); and (4) acute fulminant fungal sinusitis in 1 case (fungal vascular invasion). The diagnosis was initially missed in 16/34 (47%) cases of allergic fungal sinusitis despite typical features; incorrect classification was noted in 47% of cases. Sixty-seven percent of cases had positive fungal cultures, dematiaceous fungi being the most common. Allergic fungal sinusitis accounted for the majority of fungal sinusitis. Although misdiagnosis or incorrect classification is rather frequent for fungal sinusitis, awareness of the distinctive morphologic features of this entity may prevent these errors.

Allergic fungal sinusitis: expanding the clinicopathologic spectrum

Objective We sought to determine whether histologic tissue invasion occurs in allergic fungal sinusitis (AFS) and, if so, to identify clinical indicators for the same. Study design and setting We conducted a retrospective case record review of all 28 AFS cases identified by histology over a 32-month period at a tertiary care referral center. All histologic specimens were reevaluated for features of invasive pathology, and case records were correlated for clinical, radiologic, or laboratory parameters associated with such invasion. Results In addition to the universal finding of the characteristic allergic mucin with fungal elements on histopathologic examination of the sinus luminal contents, 6 cases (21%) had additional evidence of mucosal invasion as indicated by granulomatous inflammation and branching septate fungal hyphae in the submucosal tissues. Such coexistent invasion was associated with advanced disease as indicated by a higher incidence of orbital involvement on clinical evaluation ( P = 0.024), and extrasinus spread (intraorbital or intracranial spread) on the computed tomography evaluation ( P = 0.003). The single death that occurred on follow-up was in a patient with coexistent invasion. Conclusion Advanced AFS may be complicated by histologic evidence of tissue invasion. Significance The noninvasive and invasive forms of fungal sinusitis are not necessarily discrete and may coexist in the same patient. Clinical features of orbital involvement or computed tomography manifestations of extrasinus spread should alert the clinician to the possibility of invasion.

本邦初のＢｉｐｏｌａｒｉｓ ｓｐｉｃｉｆｅｒａによるアレルギー性真菌性副鼻腔炎

We describe a case of allergic fungal sinusitis (AFS) caused by Bipolaris spicifera, the first case reported in Japan. A 70-year-old man was admitted to our hospital because of diplopia following bilateral nasal obstruction and discharge. Radiological studies using computed tomographic scan showed a large soft tissue mass occupying the right frontal, bilateral ethmoid and sphenoid sinuses. He underwent drainage surgery and histopathological examination of the contents of the paranasal sinuses revealed scattered fungal hyphae within "allergic mucin". By cytological examination, these hyphae showed septation at irregular intervals, and were swollen to various sizes. Microbiological studies identified the fungus as Bipolaris spicifera. The presence of allergic mucin and scattered fungal hyphae were very important findings in making a diagnosis of AFS histopathologically, so squash cytology of the contents of the paranasal sinuses was quite useful to observe fungal elements and identify the strain in this case.

Preoperative Diagnosis of Allergic Fungal Sinusitis

Although the diagnosis of allergic fungal sinusitis is mainly based on characteristic histopathological findings, certain preoperative diagnostic criteria have been proposed. However, their usefulness in differentiating allergic fungal sinusitis from other sinus diseases is unknown. The objective of the study was to identify accurate preoperative diagnostic parameters for allergic fungal sinusitis. Prospective, comparative study. Twenty consecutive cases of allergic fungal sinusitis were evaluated prospectively and compared with 16 cases of ethmoidal polyposis and 5 cases of invasive sinus aspergillosis, with regard to various clinical, radiological, and immunological parameters. All patients were categorized based on histopathological findings. Nasal polyps were seen in all 20 cases of allergic fungal sinusitis, all 16 cases of ethmoidal polyposis, and 2 of 5 cases of invasive sinus aspergillosis. Computed tomography (CT) scan hyper-attenuation was seen in all 20 cases of allergic fungal sinusitis but also in 2 (13%) cases of ethmoidal polyposis and 2 (40%) cases of invasive sinus aspergillosis. Serum levels of specific anti-Aspergillus immunoglobulin E were elevated in 14 (70%) cases of allergic fungal sinusitis, 2 (13%) cases of ethmoidal polyposis, and 3 (60%) cases of invasive sinus aspergillosis. The combination of all three (ie, nasal polyps, CT scan hyper-attenuation, and elevated titers of anti-Aspergillus immunoglobulin) was not found in any case of ethmoidal polyposis or invasive sinus aspergillosis. This triad demonstrated a sensitivity of 70% and a specificity of 100% for the preoperative diagnosis of allergic fungal sinusitis. Nasal polyps, CT scan, and specific immunoglobulin E titers, when considered in combination, have a high preoperative diagnostic value in allergic fungal sinusitis. However, they should not be considered in isolation because considerable overlap occurs with invasive sinus aspergillosis and ethmoidal polyposis.

Investigations on allergic fungal genesis of chronic rhinosinusitis

The incidence of allergic fungal sinusitis (AFS) is estimated differently. The importance of hyphal findings in nasal mucus for initiation of chronic hyperplastic sinusitis is not proven. 124 patients with clinical signs and CT-scan findings of a chronic-hyperplastic rhinosinusitis were treated by functional endoscopic sinus surgery. During the operation a thick mucus was found in each patient. The mucus was isolated and investigated by histopathological analysis with special Grocott-stain and a culture for fungal growth was initiated. Furthermore the diagnostic for allergic reactions against fungus was done by prick- and RAST-tests. 21 patients had positive histopathological findings of fungus. In 10 cases fungal hyphae were found embedded in typical eosinophilic mucus. A positive allergic reaction against fungus was seen in 7 of these 10 patients. The culture results showed different pictures according to the isolated species, in 3 cases of the 10 AFS cases the culture was negative. The other 11 cases of 21 positive histological findings of fungus were cases of a fungus ball. The other 103 patients were without any sign for fungus in the HE- or Grocott-stain. A high incidence of AFS is not evident in group of chronic hyperplastic rhinosinusitis. The presence of eosinophilic "allergic" mucus is not the evidence for AFS. The inflammatory cascade leading to the clinical picture is a multifactorial event. The role of detectable fungus hyphae have to be estimated by further investigations.

Study of allergic fungal sinusitis in 40 surgical cases of chronic paranasal sinusitis

Allergic fungal sinusitis is chronic and paranasal, related to fungal allergy. Many papers on allergic fungal sinusitis have been reported in the United State, and the incidence is 5% to 10% among patients with chronic paranasal sinusitis. Although cases of allergic fungal sinusitis have been reported in Japan, the incidence is unclear. We studied allergic fungal sinusitis in 40 consecutive patients--26 men and 14 women--undergoing endoscopic sinus surgery at Keiyukai Sapporo Hospital December 2000 to July 2001. We checked for allergic rhinitis and asthma, a history of surgery for nasal polyps and chronic sinusitis, the presence of nasal polyps, grading of sinusitis via computed tomography, nonspecific IgE and allergen-specific IgE for fungi in serum, eosinophilia in nasal smears, paranasal eosinophilic mucin, and histology and fungal culture of paranasal sinus mucus. None had typical allergic fungal sinusitis, but 1 had eosinophilic paranasal mucin, high IgE, and false-positive IgE for fungi. We studied clinical data and histology of fungi and paranasal mucosa in 9 cases with fungal maxillary sinusitis, but none had allergy or eosinophilic mucin. This suggested that few patients with allergic fungal sinusitis exist among those with chronic paranasal sinusitis.

Eosinophilic Mucin Rhinosinusitis: A Distinct Clinicopathological Entity

Allergic fungal sinusitis (AFS) was recognized in 1981. Since 1983, a form of sinusitis histologically similar to AFS except for the absence of fungal hyphae has also been noted. The designation "eosinophilic mucin rhinosinusitis (EMRS)" is proposed. Its relationship to AFS is controversial and problematic. To determine whether distinctive clinical and immunological differences exist to differentiate the histological entity of EMRS from AFS. Literature review and comparison of cases of AFS (n = 418) to EMRS (n = 40) from the literature, as well as cases of AFS (n = 13) and EMRS (n = 29) accrued in the present study. A total of 431 AFS patients were compared with 69 EMRS patients. The mean age of patients with AFS was significantly younger than patients with EMRS (30.7 y compared with 48.0 y, respectively; P < .001). Male-to-female ratios were 1.03:1 and 1.26:1 for AFS and EMRS, respectively, and were not significantly different. Forty-one percent of patients with AFS were asthmatic compared with 93% of patients with EMRS (P < .0001). Thirteen percent of patients with AFS were aspirin sensitive compared with 54% of patients with EMRS (P < .0001). Polyp occurrence was almost 100% in both groups. Eighty-four percent of patients with AFS had allergic rhinitis (AR), while only 63% of patients with EMRS had AR (P = .004). Fifty-five percent of AFS patients had bilateral disease, in contrast to the 100% of EMRS patients with bilateral disease (P < .0001). Although average total immunoglobulin E (IgE) was elevated in both groups, it was significantly more elevated in AFS patients (range, 12-13,084 mg/ dL; mean, 1,941 mg/dL) compared with EMRS patients (range, 14-1,162 mg/dL; mean, 267 mg/dL; P < .001). Total immunoglobulin G (IgG) and IgG subclasses were seldom reported in the cases available from the literature of either AFS or EMRS. However, in the present series of EMRS, IgG1 deficiency occurred in 50% of evaluated patients (mean, 475 +/- 175 mg/dL; range, 250-869 mg/dL; normal, 422 to 1,200 mg/dL) but in no cases of AFS reported in the literature. Significant clinical and immunological differences exist to distinguish AFS from EMRS. It is postulated that AFS is an allergic response to fungi in predisposed individuals, while EMRS occurs because of a systemic dysregulation of immunological controls. Because EMRS is a systemic disease, unilateral disease is not seen. In contrast, AFS, an allergic response to fungi, may occur unilaterally or bilaterally depending on the antigenic stimulation. EMRS also has a significantly higher association with asthma, an increased incidence of aspirin sensitivity, and an increased incidence of IgG1 deficiency. Therapy with a systemic steroid, a potent and indiscriminant anti-inflammatory agent, is a useful adjunct in both disorders. Fungal immunotherapy following surgical extirpation of AFS is useful in preventing AFS recurrence. It is predicted that fungal immunotherapy and antifungal agents will be ineffective in patients with EMRS. It is important to differentiate these two similar histopathological entities in future trials assessing therapeutic efficacy. Inclusion of both entities in a study could obscure recognition of the true effectiveness of intervention, because of the possible variable response differences between the two entities. This study shows that significant clinical and immunological differences exist between EMRS and AFS. The future awaits an exploration of the pathophysiological basis of these differences.

Further evidence for allergic pathophysiology in allergic fungal sinusitis.

Controversy continues over whether allergic fungal sinusitis represents a true allergy, an infection, or a point somewhere along a spectrum between allergy and infection. The present study describes two experiments that add weight to the argument that allergic fungal sinusitis (AFS) is truly an immunologically mediated hypersensitivity and not a form of infection. In the first experiment, eight patients with Bipolaris culture-positive AFS were prospectively evaluated with Bipolaris antigen skin testing and with inhibition radioallergosorbent (RAST) and enzyme-linked immunosorbent assay (ELISA) for Bipolaris-specific IgE and IgG antibodies. The Bipolaris AFS cases were compared with 10 control patients with no history of AFS. All eight AFS cases demonstrated positive skin testing to Bipolaris and in addition, all tested positive by RAST and ELISA for IgE and IgG Bipolaris antibodies, respectively. In the control group one patient had a positive skin test, ELISA, and RAST and one additional patient had a positive ELISA only. Good correlation was noted between skin test, RAST, and ELISA results. In the second experiment, sinus mucosa from 14 AFS patients and 10 control patients with other forms of surgical sinus disease was analyzed by immunohistocytochemistry for the eosinophilic inflammatory mediators major basic protein (MBP) and eosinophil derived neurotoxin (EDN) and the neutrophil mediator neutrophil elastase. All AFS cases demonstrated evidence of eosinophilic mediator release, and MBP and EDN predominated over neutrophil elastase. In the control group eosinophil and neutrophil mediator release in sinus mucosa was equal. The two experiments support the concept that AFS is an antigen-triggered, IgE- and IgG-mediated hypersensitivity response with a late-phase inflammatory reaction involving release of eosinophilic mediators.

Evaluation and treatment of allergic fungal sinusitis. I. Demographics and diagnosis

Background: Few cases of allergic fungal sinusitis have been systematically evaluated to conclusively confirm working clinical, histopathologic, and serologic diagnostic criteria. Objectives: The objective of this study was to describe 67 consecutive cases of allergic fungal sinusitis, the largest number of cases yet published. Methods: Cases from 1 practice over 8 years were evaluated with a consistent protocol, including skin testing, serum chemistries and serologies, and surgical specimen analysis. Results: All patients were atopic (100%) and had nasal polyposis (100%). They tended to be young (33.3 ± 13.1 years, mean ± SEM), immunocompetent (92%; remaining 8% with low quantitative immunoglobulin but normal function), have slight female preponderance (58%), have a history of hypertrophic rhinosinusitis (100%), report nasal cast production (75%), and have developed their disease in the southwestern United States. Bipolaris spicifera was the most prevalent fungus involved (67%). Total serum IgE (mean 668 IU/mL) and fungal-specific IgG were generally elevated, whereas fungal-specific precipitins and specific IgE were generally negative despite positive fungal-specific immediate hypersensitivity skin tests. Conclusions: Patients with allergic fungal sinusitis tend to have elevated total serum IgE and fungal-specific IgG at diagnosis but not fungal-specific IgE or precipitins. Histopathologic criteria for allergic fungal sinusitis diagnosis are discussed. The southwestern United States appears to be a “hot spot” for the disease, particularly caused by B spicifera. (J Allergy Clin Immunol 1998;102:387-94.)

Evaluation and treatment of allergic fungal sinusitis. II. Treatment and follow-up

Background: Previous allergic fungal sinusitis case reports have speculated that oral corticosteroids might reduce the severity of disease and possibly forestall the high rate of recurrent sinus surgery. Objectives: Our objective was to comprehensively review 67 consecutive cases of allergic fungal sinusitis for their response to treatment and the utility of monitoring patient serologies during clinical follow-up. Methods: Allergic fungal sinusitis cases from a private practice were evaluated and treated with consistent diagnostic criteria and treatment paradigms. An 8-year retrospective review of serologic parameters and clinical response to treatment with or without oral corticosteroids is described. Results: The total serum IgE was found to correlate with the clinical rhinosinusitis severity ( P = .0002). The fungal-specific IgG also correlated with clinical rhinosinusitis severity but less rigorously ( P = .004). An increase of 10% or more in total serum IgE during follow-up was found to have significant predictive value for recurrent surgical intervention, with a sensitivity of 79%, specificity of 77%, positive predictive value of 48%, and negative predictive value of 93% ( P < .0001). With the use of a modified corticosteroid treatment regimen adapted from allergic bronchopulmonary aspergillosis, as little as 2 months of oral corticosteroids after surgery provided significant clinical improvement for up to 12 months ( P < .0001), although patients taking 12 months of treatment fared the best clinically ( P = .03). By survival analysis, oral corticosteroids prolonged the time between subsequent sinus surgeries ( P = .01) in this highly recurrent disease. No significant side effects of oral corticosteroids were observed during treatment with this dosing regimen. Conclusions: Postoperative oral corticosteroids appear to be an effective treatment option for allergic fungal sinusitis, and monitoring of total serum IgE can be helpful in the clinical follow-up of these patients. (J Allergy Clin Immunol 1998;102:395-402.)

Orbital Involvement in Allergic Fungal Sinusitis

Although allergic fungal sinusitis is a relatively common, noninvasive form of paranasal sinus mycosis, and despite frequent orbital involvement, there have been few reports of this condition in the ophthalmic literature. Two cases of allergic fungal sinusitis having orbital symptoms are described. The current classification, typical presentation, and ideal management of fungal sinusitis are reviewed. Distinguishing radiologic and pathologic features were present in both patients. Aspergillus flavus was cultured in one case, and Bipolaris spicifera was cultured in the other. Allergic fungal sinusitis is a unique subset of sino-orbital disease with highly characteristic clinical, radiologic, and pathologic features. Unlike invasive forms of mycotic disease, allergic fungal sinusitis may be managed adequately with surgical debridement, aeration of the involved sinuses, and systemic and topical corticosteroids.

Paranasal sinus fungus balls

Background Paranasal sinus fungus balls (mycetomas) are a form of fungal sinus infection distinct from allergic fungal sinusitis, fulminant invasive fungal disease, and paranasal aspergillus granulomas. Methods The Mayo Clinic surgical pathology files of inflammatory sinus specimens from 1984 to 1994 were examined. Twenty-nine paranasal sinus fungus balls were identified. Cases of allergic fungal sinusitis and invasive fungal disease were excluded. Results The fungus balls occurred in 11 men and 18 women, with an age range of 28 to 86 years, mean 64 years. Sinuses involved included maxillary (20 cases), sphenoid (10 cases), ethmoid (9 cases), and frontal (6 cases). In 12 patients, multiple sinuses were involved in a variety of combinations. By culture the most common pathogens were Aspergillus fumigatus and Aspergillus flavus. Treatment was by a variety of surgical procedures. Follow-up in 28 patients showed two recurrences and three deaths due to intracerebral bleed as a complication of surgery. These deaths occurred in patients with sphenoid sinus fungus balls. Conclusions Paranasal sinus fungus balls occur in an elderly population and have a female predominance. They have a low morbidity and recurrence rate. Death can occur in sphenoid sinus lesions as a complication of surgery. © 1997 John Wiley & Sons, Inc. Head Neck 19:481–486, 1997.