Treatment Of Allergic Fungal Rhinosinusitis Research Articles

Bilateral proptosis with hypertelorism - An unusual presentation of extensive allergic fungal sinusitis

Allergic fungal rhinosinusitis (AFRS) is one of the most common form of fungal sinusitis. It is a hypersensitivity reaction to fungal infection. The patients are either atopic or immunocompetent. Such patients suffer from rhinosinusitis. The allergic mass is expanding in nature and this results in bony remodelling. It also involves the adjacent structures. Ophthalmological complications occur when the mass involves orbit. These complications include diplopia, telecanthus, proptosis, malar flattening, epiphora, asthenopia and even visual loss. The diagnosis can be made using radiological imaging. Histopathological examination is needed to confirm the diagnosis. The treatment of AFRS includes both surgical and medical therapy. This case report demonstrates a rare presentation of the non-invasive AFRS with bilateral proptosis with hypertelorism. The patient showed a drastic improvement after endoscopic sinus surgery, oral anti fungal medication, oral steroids and nasal saline irrigation.

Various Postoperative Medical Lines for Management of Allegic Fungal Rhinosinusitis (Meta-Analyical Study)

Abstract Background Allergic fungal rhinosinusitits (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 allergic fungal rhinosinusitis usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal post-operative medical regimen is still controversial. Hence, the purpose of this study is to assess the efficacy of various postoperative medical lines for management of AFRS. Objective To find out the role and efficacy of various medical therapies for postoperative treatment of allergic fungal rhinosinusitis (through a systematic review study). Materials and Methods Fifty studies were included in the present systematic review and meta-analysis, the total number of patients included in all studies (No = 1,655 patients). Our review has investigated the literature on 5 medical therapies (steroids, antifungal, immunotherapy, mepolizumab, and omalizumab) concerning the management of postoperative AFRS patients. Results The results showed that the recurrence rate after postoperative systemic steroids was 26.3%, topical steroids was 38.4%, antifungals therapy was 32.1%, immunotherapy was 17.4%, the percentage of recurrence after combination of antifungal and steroids was 9.6%, recurrence risk difference between antifungal and placebo was 18.2%, recurrence risk difference between steroids and placebo was 6.5%. Base on the above results, the combination of steroids and antifungal therapy is the best treatment for postoperative patients with AFRS. Conclusion This review investigated the literature on 5 medical therapies (steroids, antifungal, immunotherapy, mepolizumab, and omalizumab) concerning the management of postoperative AFRS, and provided an evidence-based review with recommendations, the use of steroids alone or antifungals as well, resulted in some degree of recurrence reduction in disease, the evidence supports the use of postoperative combination (oral steroids and systemic antifungal) as a better line of post-operative medical treatment in AFRS patients.

A case series on allergic fungal rhino sinusitis – variable presentations

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.

Presentation and management of allergic fungal rhinosinusitis in children

Objective:To assess the presentation of allergic fungal rhinosinusitis（AFRS） in children and the role of long-term comprehensive therapy of endoscopic surgery combined with drug therapy. Methods:The 3 children with AFRS were routinely examined by nasal endoscopy, CT scan, MRI scan and allergen detection before surgery, and mycological and histomathological examination were performed on the secretions in the sinus and the mucosa of the affected sinuses. All the 3 patients underwent endoscopic surgery, preoperative and postoperative treatment with oral and nasal corticosteroid, nasal irrigation, and individualized anti-allergy therapy and immunotherapy. The patients were followed up for 3 to 12 months. Results:All 3 children had nasal polyps and headache, and 2 children had exophthalmos and facial asymmetry. There were typical CT and MRI findings on imaging. Serum total IgE were all elevated, and 2 cases were positive for fungal SIgE. All 3 children underwent endoscopic surgery. Fungal hyphae and spores were found in 1 child, and other fungi tests were positive in another 2 children. Postoperative facial asymmetry was relieved spontaneously, and mucosal swelling and polypoid changes were observed in 2 children. Conclusion:AFRS is a specific type of chronic rhinosinusitis that is not uncommon in children. Early diagnosis, prompt operation, standardized treatment and long-term follow-up are very important in the diagnosis and treatment of AFRS in children.

Analysis of differential expression of protease-activated receptors in patients with allergic fungal rhinosinusitis.

BackgroundEver since its characterization in the 1970s, allergic fungal rhinosinusitis (AFRS) has been the subject of much controversy, especially regarding its pathogenesis. In this study, we analyzed the differential expression of genes that encode protease-activated receptors (PAR) in patients with AFRS and patients with chronic rhinosinusitis, and tried to understand the pathogenic basis of this disease.ObjectiveTo analyze the differential expression of PAR genes in patients with AFRS and in patients with chronic rhinosinusitis.MethodsMucosa from ethmoid sinuses of 51 patients (tests and controls) was biopsied and evaluated for messenger RNA expression of PAR genes by using reverse transcriptase–polymerase chain reaction. Each of the four PAR genes, i.e., par1, par2, par3 and par4 was amplified, the final gene products were run on 1.8% agarose gel and analyzed by densitometry to calculate differential expression. The significance level was determined as p ≤ 0.05.ResultsIt was observed that the expressions of all four par genes were higher in the test samples compared with the controls, but statistical significance was achieved only for par1 (p=0.004) and par2 (p=0.05). Comparative expression of the four PAR genes was also performed within the test and control groups, and a statistically significant difference was seen between par1 and par2 (p=0.007), par1 and par3 (p=0.029), par1 and par4 (p=0.0001), par2 and par4 (p=0.002), and par3 and par4 (p=0.009) in the test group. In the control group as well, par1, par2, and par3 exhibited a higher expression compared with par4 but the difference was significant between par3 and par4 genes only.ConclusionPatients with AFRS expressed increased levels of PAR genes in their nasal mucosa, and, of the four PAR genes, a higher expression of par1, par2, and par3 was observed in both the groups compared with par4. This information contributes toward our understanding of pathogenesis and possibly treatment of AFRS.

Comparison of Steroid and Itraconazole for Prevention of Recurrence in Allergic Fungal Rhinosinusitis: A Randomized Controlled Trial.

Allergic Fungal Rhinosinusitis (AFRS) is due to the continuous exposure of fungal antigens to an atopic individual. Medical treatment following the surgery is the standard protocol often practiced for the treatment of AFRS. Steroid (systemic/topical) has been considered as the standard medical treatment for the control of the disease in AFRS although most of the patients show recurrence with long term follow up. Instead, antifungals (itraconazole) can be tried to decrease the recurrence rate which acts by inhibiting the fungal growth in the postoperative period. In the current study, we have compared the efficacy between steroid and the itraconazole in preventing the recurrence of the disease in patients with AFRS in postoperative period. This prospective study was conducted in the Department of Otorhinolaryngology in a tertiary care referral hospital from October 2013 to February 2015. Total 60 patients with AFRS with nasal polyposis, diagnosed by Bent-Kuhn's criteria were included in the study. For patients of Group A (containing 30 patients), systemic steroid (oral prednisolone 30 mg OD) was continued for one month and afterwards topical steroid (nasal spray) was continued till six months after surgery. In Group B (containing 30 patients), oral itraconazole (100 mg BID) was continued for six months. Clinical and haematological parameters were compared at the end of six months. The average pre-treatment and post treatment scores of Absolute Eosinophil Count (AEC) in the patients of Group A was 532 μg/l and 482 μg/l respectively and the corresponding values in Group B were 578 μg/L and 438 μg/L respectively at the end of six months (p=0.912). Similarly, the preoperative and postoperative serum IgE level in Group A was 886.20 IU/ml and 620 IU/ml and the respective values in Group B were 935 IU/ml and 570 IU/ml (p=0.555). Mean preoperative and postoperative mean SNOT score in Group A and Group B were 52.5 in 34.3 and respective values in Group B were 55.7 and 29.5. Itraconazole can be considered as an effective treatment alternative to the steroid for postoperative management of AFRS. Although there was no significant difference noted between two groups, patients treated with itraconazole had a better symptomatic relief and endoscopic clearance of disease.

Diagnosis and treatment of allergic fungal rhinosinusitis

Diagnosis and treatment of allergic fungal rhinosinusitis

Role of immunotherapy in allergic fungal rhinosinusitis.

Our understanding of the pathogenesis and treatment of allergic fungal rhinosinusitis (AFRS) continues to evolve. This article serves to update the reader on the diagnosis and management of AFRS and pays particular attention to the recent literature regarding efficacy and safety of immunotherapy in this patient population. The mainstay of treatment of AFRS remains a thorough surgery; however, adjunctive medical management is also critical to achieve optimal outcomes. Oral steroid use in AFRS remains recommended. Immunotherapy, both fungal and nonfungal, may be considered for patients exhibiting a type I hypersensitivity to specific allergens. To date, limited studies do show improvement with reduction of postoperative exacerbations and revision surgeries. There remains no evidence of unusual side-effects or formation of immune complexes from immunotherapy in AFRS patients. Double-blind placebo controlled trials on immunotherapy and AFRS are lacking, and ultimately, conclusive evidence of efficacy is not present to date. Treatment of AFRS requires multimodality therapy with immunotherapy playing a significant, yet inconclusive, role. Further studies remain warranted.

Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations.

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.

Efficacy of Preoperative Itraconazole in Allergic Fungal Rhinosinusitis

Objectives:Gold standard treatment of allergic fungal rhinosinusitis (AFS) is primary surgery followed by adjuvant therapy. Even after good surgery, recurrence rates vary from 10 to 79%. Antifungals like itraconazole and steroids have shown varying success rates in delaying recurrences given postoperatively. Itraconazole decreases need for steroids given as a primary treatment in allergic bronchopulmonary aspergillosis. This study investigates the efficacy of Itraconazole given preoperatively in AFS.Methods:A prospective study was carried out from July 2011 to December 2012 on twenty histologically proven patients of AFS, who were given Itraconazole preoperatively for 1 month, operated subsequently. They were compared with 20 matched controls of AFS cases, operated directly without preoperative itraconazole. Both groups were given oral steroids for 6 weeks postoperatively and followed for 3 months. Evaluations were done using symptomatic (SNOT score), radiologic (Lund Mackay scores) and endoscopic (Kupferberg Grades) parameters.Results:Symptomatology scores (SNOT20) decreased significantly (p=0.000) with Itraconazole. There was a significant decrease (p=0.005) in Lund Mackay scores reaching to 0 with complete resolution of disease in 15% cases with reduced hyper densities noted in all. Polyp sizes decreased and nasal endoscopic grades improved. Postoperative fungal cultures were positive in 45% compared to 79% cases among control group suggesting a decreased fungal burden. Total serum IgE decreased with itraconazole and had positive correlation (c.c=0.68) with postoperative fungal culture.Conclusions:We found improvements in clinical, radiologic, and endoscopic parameters in AFS after preoperative Itraconazole administration, decreasing the disease load significantly. It may prove to be a good preoperative adjunct needing further research.

Fungal rhinosinusitis: what every allergist should know

The interaction between fungi and the sinonasal tract results in a diverse range of diseases with an equally broad spectrum of clinical severity. The classification of these interactions has become complex, and this review seeks to rationalize and simplify the approach to fungal diseases of the nose and paranasal sinuses. These conditions may be discussed under two major headings: non-invasive disease (localized fungal colonization, fungal ball and allergic fungal rhinosinusitis) and invasive disease (acute invasive rhinosinusitis, chronic invasive rhinosinusitis and granulomatous invasive rhinosinusitis). A diagnosis of fungal rhinosinusitis is established by combining findings on history, clinical examination, laboratory testing, imaging and histopathology. The immunocompetence of the patient is of great importance, as invasive fungal rhinosinusitis is uncommon in immunocompetent patients. With the exception of localized fungal colonization, treatment of all forms of fungal rhinosinusitis relies heavily on surgery. Systemic antifungal agents are a fundamental component in the treatment of invasive forms, but are not indicated for the treatment of the non-invasive forms. Antifungal drugs may have a role as adjuvant therapy in allergic fungal rhinosinusitis, but evidence is poor to support recommendations. Randomized controlled trials need to be performed to confirm the benefit of immunotherapy in the treatment of allergic fungal rhinosinusitis. In this article, we will summarize the current literature, addressing the controversies regarding the diagnosis and management of fungal rhinosinusitis, and focussing on those aspects which are important for clinical immunologists and allergists.

Allergic fungal rhinosinusitis: diagnosis and management

The proper diagnosis and treatment of allergic fungal rhinosinusitis remain controversial. We discuss recent additions to the literature regarding diagnosis and treatment of this condition. There is considerable overlap in the clinical features of allergic fungal rhinosinusitis and other forms of eosinophilic mucin chronic rhinosinusitis. Type 1 hypersensitivity and characteristic computed tomographic findings may have predictive value for a final diagnosis of allergic fungal rhinosinusitis, patients with which are more likely to have bony erosion than patients with other forms of chronic rhinosinusitis. The decreases in orbital volume associated with expansive allergic fungal rhinosinusitis disease may spontaneously improve after successful treatment. Most patients have detectable fungal-specific IgE in their so-called allergic mucin. Elevated levels of fungal-specific IgG3 are a consistent finding in patients with allergic fungal rhinosinusitis and eosinophilic mucin chronic rhinosinusitis. Antifungal treatment is still considered a treatment option, but further study is needed. Type 1 hypersensitivity to fungal antigens helps to distinguish allergic fungal rhinosinusitis from other forms of eosinophilic mucin chronic rhinosinusitis. Bony erosion and orbital expansion giving rise to proptosis are prominent features of allergic fungal rhinosinusitis. Advances in medical treatment will require prospective and controlled trials.

Targeted endoscopic surgery for allergic fungal rhinosinusitis

The current, most widely accepted protocol for the treatment of allergic fungal rhinosinusitis includes endoscopic sinus surgery, followed by a prolonged course of steroid treatment. We describe a new protocol for the perioperative treatment of allergic fungal rhinosinusitis: (1) preoperative prednisone 1 mg/kg/d for 10 days; (2) computerized tomography (CT) 1 day before surgery; (3) endoscopic sinus surgery targeted to allergic mucin foci remnants according to their precise location as seen on CT after steroid treatment; and (4) postoperative tapering of prednisone over 6-9 days. Preoperative treatment with high-dose steroids provides the endoscopic surgeon with a surgical field that is much easier to control. Precision surgery reduces operation time and can obviate unnecessarily extensive surgery and potentially associated complications. According to our experience, this management appears to improve the outcome of patients with allergic fungal rhinosinusitis compared to the outcome of alternative approaches described in the literature.

Natural history of allergic fungal rhinosinusitis: a 4- to 10-year follow-up.

Numerous studies have noted the high rate of recidivism after the initial treatment of allergic fungal rhinosinusitis (AFS). Short-term studies have revealed varying recurrence rates based on therapy; however, little is currently known about the long-term natural history of the disease. Our goal was to address the question of long-term outcomes in AFS patients and make observations about the natural history of the disease. Seventeen patients with follow-up ranging from 46 to 138 months were examined and interviewed, and their charts were reviewed. A quality-of-life survey was completed, and blood was drawn to measure immunoglobulin levels. All patients initially underwent treatment with a combination of surgery, systemic and/or topical corticosteroids, and immunotherapy to pertinent fungal and nonfungal antigens. Normalization of sinonasal mucosa (Kupferberg stage 0) was seen in 5 (29%) of 17 patients, whereas 76% demonstrated either normal or slight mucosal edema (Kupferberg stage 0 or 1). Serologic testing revealed fungus-specific IgE significantly elevated in all 17 patients. The initial choice of therapy did not appear to affect the long-term outcome, and patients tended to be doing well overall. These results suggest that after successful initial treatment and control of AFS, many patients can achieve a quiescent disease state.