Comprehensive Management of Allergic Fungal Sinusitis

In little more than a decade, allergic fungal sinusitis has gone from a medical curiosity to one of the more perplexing problems to challenge the otorhinolaryngologist. These patients are typically immunocompetent adolescents or young adults with pansinusitis (unilateral and bilateral) and polyposis, atopy, and characteristic radiographic findings. Allergic mucin contained within the sinuses demonstrates numerous eosinophils and Charcot-Leyden crystals, and fungal stains show the presence of noninvasive hyphae. Fungal cultures may or may not be positive. We have found the following approach to allergic fungal sinusitis to be most effective: 1) Adequate preoperative evaluation and medical preparation; 2) Meticulous exenterative surgery; 3) Closely supervised immunotherapy with relevant fungal and non-fungal antigens; 4) Medical management including topical and systemic corticosteroids as needed; 5) Irrigation and self-cleansing by the patient; and 6) Close clinical follow-up with endoscopically guided debridement when necessary.

Download Full-text

Allergic Mucin With and Without Fungus

Archives of Pathology & Laboratory Medicine ◽

10.5858/2001-125-1442-amwawf ◽

2001 ◽

Vol 125 (11) ◽

pp. 1442-1447

Author(s):

Jonathan F. Lara ◽

J. Daniel Gomez

Keyword(s):

Tertiary Care ◽

Fungal Sinusitis ◽

Allergic Fungal Sinusitis ◽

Radiographic Findings ◽

Care Institution ◽

Tertiary Care Institution ◽

Allergic Mucin ◽

And Gender

Abstract Context.—Allergic mucin, a lamellated collection of inspissated inflammatory debris, has been a hallmark of allergic fungal sinusitis. While its identification is a clue for pathologists to search for fungi, and directs clinicians toward specific therapy and follow-up, recent reports describe cases with allergic mucin but without concomitant fungus. The absence of such organisms in otherwise typical allergic mucin brings into question the role of fungi in allergic fungal sinusitis. Objectives.—To study clinical and pathologic differences between patients with allergic mucin in surgical nasal resection specimens and to elucidate the role of fungus in allergic sinusitis. Design.—Patients with histologic evidence of allergic mucin, with and without fungus, were identified and retrieved from the surgical pathology files of a tertiary-care institution. The patients were separated into 2 groups for analysis, and their clinical and pathologic findings were reviewed and compared. Setting.—Tertiary-care institution. Patients.—All patients who underwent sinus mucosal resection between 1992 and 1998. Results.—Clinical presentation and radiographic findings were similar in both groups. Incidence, age, and gender distribution were similar to data reported previously. However, the amount of allergic mucin was much greater in the group with fungus than in the group without fungus, which to our knowledge is an unreported observation to date. Conclusion.—The presence of allergic mucin is not unique to allergic fungal sinusitis, but rather is the result of a process that could have other etiologies. While perhaps not always causative to the disease, the fungus continues to fuel the process and is likely an entrapped bystander. Allergic fungal sinusitis is more appropriately termed allergic mucinous sinusitis or eosinophilic mucinous rhinosinusitis.

Download Full-text

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

The Journal of Laryngology & Otology ◽

10.1017/s0022215107006226 ◽

2007 ◽

Vol 121 (11) ◽

pp. 1055-1059 ◽

Cited By ~ 9

Author(s):

A K Gupta ◽

S Bansal ◽

A Gupta ◽

N Mathur

Keyword(s):

Visual Loss ◽

Case Series ◽

Lateral Wall ◽

Contralateral Side ◽

Pathophysiological Mechanism ◽

Fungal Sinusitis ◽

Allergic Fungal Sinusitis ◽

Laboratory Findings ◽

Fungal Antigens ◽

Fungal Serology

AbstractObjective:To hypothesise the probable pathophysiological mechanism responsible for visual loss in allergic fungal sinusitis, other than direct compression.Design: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.Interventions: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.Outcome measures:Improvement in vision.Results:All four cases experienced an improvement in vision: full recovery in three cases and partial improvement in one case.Conclusion: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.

Download Full-text

Minitrephination as an Adjunctive Measure in the Endoscopic Management of Complex Frontal Sinus Disease

American Journal of Rhinology ◽

10.2500/ajr.2007.21.3083 ◽

2007 ◽

Vol 21 (5) ◽

pp. 629-636 ◽

Cited By ~ 12

Author(s):

Alen N. Cohen ◽

Marilene B. Wang

Keyword(s):

Los Angeles ◽

Frontal Sinus ◽

Medical Center ◽

Retrospective Chart Review ◽

Sinus Surgery ◽

Endoscopic Management ◽

Fungal Sinusitis ◽

Allergic Fungal Sinusitis ◽

Sinus Disease

Background Frontal sinus disease and its surgical management continues to remain an area of controversy among rhinologists. This is evidenced by the multitude of surgical procedures, both external and endoscopic, that have been developed in its management. This study was performed to evaluate the safety and efficacy of frontal sinus minitrephination in combination with endoscopic frontal sinus exploration for the management of complex frontal sinus disease. Methods A retrospective chart review identified 13 patients treated with minitrephination, in conjunction with endoscopic frontal sinus exploration, at the University of California at Los Angeles Medical Center or West Los Angeles VA Medical Center from July 2004 to October 2005. Results Thirteen patients with diagnoses of chronic sinusitis (n = 10), nasal polyposis (n = 7), frontal mucocele (n = 4), allergic fungal sinusitis (n = 3), and inverting papilloma (n = 1) underwent either unilateral (n = 9) or bilateral (n = 4) minitrephination during primary or revision functional endoscopic sinus surgery. Median follow-up was 14.2 months. There were no complications attributed to the procedure, and all patients had improvement of their sinus symptoms and displayed no evidence of recurrence of their frontal sinus disease at last follow-up. Conclusion Minitrephination is a safe and effective adjunct in the management of complex frontal sinus disease, as it allows identification of the frontal recess and vigorous irrigation of the sinus contents.

Download Full-text

Allergic Fungal Sinusitis: A Four-Year Follow-Up

American Journal of Rhinology ◽

10.2500/105065800782102780 ◽

2000 ◽

Vol 14 (3) ◽

pp. 149-156 ◽

Cited By ~ 57

Author(s):

Frederick A. Kuhn ◽

Amin R. Javer

Keyword(s):

Treatment Protocol ◽

Staging System ◽

Current Treatment ◽

Sinus Surgery ◽

Total Serum ◽

Fungal Sinusitis ◽

Allergic Fungal Sinusitis ◽

System A ◽

Fungal Load

Allergic fungal sinusitis (AFS), first described over 18 years ago and subsequently identified using established criteria, remains a challenge to treat. Our protocol has included complete functional endoscopic sinus surgery to remove the fungal load and restore physiologic mucous clearance. The patient is treated with prednisone for several months and followed monthly with total serum IgE levels and an established endoscopic mucosal staging system. A group of 11 patients first treated in 1994 and presented at the 1995 American Rhinology Society Spring meeting are being presented again to provide an update on their progress over the past four years. A great deal of experience has been gained from their treatment and has continued to modify our postoperative medical management. An overview of AFS, our evolving and current treatment protocol, and possible future trends are discussed in this paper.

Download Full-text

Allergic Mucin Sinusitis without Fungus

American Journal of Rhinology ◽

10.2500/105065897782537269 ◽

1997 ◽

Vol 11 (2) ◽

pp. 145-148 ◽

Cited By ~ 31

Author(s):

Hassan H. Ramadan ◽

Huma A. Quraishi

Keyword(s):

Clinical Picture ◽

Nasal Polyposis ◽

Clinical Presentation ◽

Fungal Sinusitis ◽

Asthma Treatment ◽

Allergic Fungal Sinusitis ◽

Fungal Hyphae ◽

History Of ◽

Allergic Mucin

Allergic fungal sinusitis (AFS) is a distinct clinical pathologic entity that has been recognized for over a decade. The hallmark of this process is eosinophilic allergic mucin with fungal hyphae on histopathology. We have identified a subset of patients who present with a clinical picture similar to that of AFS patients in which fungus could not be demonstrated pathologically or on culture. We present four cases of allergic mucin sinusitis without fungus. A comparison of the clinical presentation of this group of patients with those with AFS will be discussed. Both groups had nasal polyposis and a history of multiple sinonasal procedures. By contrast, the patients with allergic mucin sinusitis were older than the AFS group. All of the patients with allergic mucin sinusitis also had asthma. Treatment was the same for both groups of patients.

Download Full-text