Treatment of allergic fungal sinusitis: A comparison trial of postoperative immunotherapy with specific fungal antigens

Objective: To determine the effect of immunotherapy (IT) with fungal antigens on clinical outcome in patients with allergic fungal sinusitis (AFS). Study Design: Prospective case control. Methods: In this comparison study, 22 patients meeting the diagnostic criteria of allergic fungal sinusitis (AFS) were evaluated after a mean of 33 months' therapy. All received similar treatment consisting of endoscopic sinus surgery, corticosteroids, and antibiotics as needed for complicating purulent sinusitis. Eleven patients received postoperative immunotherapy (IT) with fungal and nonfungal antigens to which sensitivity had been demonstrated, while the remaining 11 received no immunotherapy. Results: The effect of IT was to significantly improve patient outcome as assessed objectively by an AFS endoscopic mucosal staging system (P < .001) and a sinusitis-specific quality-of-life scale, the Chronic Sinusitis Survey (P = .002). In addition, IT was shown to reduce reliance on systemic (P < .001) and topical nasal (P = .043) corticosteroid therapy to control disease. Follow-up was similar in the two groups and was not a determinant of differences in outcome (P = .7). Conclusions: Results from this study indicate that specific IT with fungal antigens improves patient outcome in AFS. Laryngoscope, 108:1623–1627, 1998     

Response of visual loss in allergic fungal sinusitis to oral corticosteroids

Visual loss associated with allergic fungal sinusitis is most often treated with surgery followed by oral corticosteroids. A case is presented in which, because of substantial medical comorbidities, surgery could not be initially performed and the visual loss was corrected with prednisone alone. This case serves to reinforce the central role of corticosteroids in treatment of this enigmatic condition.     

Th2 immunological inflammation in allergic fungal sinusitis, nonallergic eosinophilic fungal sinusitis, and chronic rhinosinusitis

BACKGROUND: Noninvasive fungal sinusitis is a heterogenous group of conditions including allergic fungal sinusitis (AFS) and nonallergic eosinophilic fungal sinusitis (NEFS). Th2-mediated cascades have been postulated to be the major inflammatory response in patients with AFS although other mechanisms also may be involved. The detailed mucosal Th2 cytological status of NEFS still has not been studied in great depth. METHODS: Using a meticulous patient selection algorithm over a 2-year period, infundibular mucosal tissue from patients with AFS, NEFS, chronic rhinosinusitis (CRS), and normal controls was studied (n = 59). Immunohistochemistry for mast cells, eosinophils, and immunoglobulin E (IgE) cells was performed and cell counts per unit area were measured. RESULTS: Mast cell, eosinophil, and IgE+ cell numbers were significantly raised in patients with AFS, NEFS, and CRS when compared with controls. There was no significant difference between cell numbers in patients with AFS and NEFS. CONCLUSION: Patients with AFS exhibit a classic Th2 inflammatory response in nasal mucosal tissue with NEFS and CRS patients showing evidence of a similar Th2 cascade, including the presence of IgE+ cells.     

变应性真菌性鼻窦炎的综合治疗

目的 探讨内、外科综合治疗手段对变应性真菌性真窦炎的治疗作用。方法 对31例变应性真菌性鼻窦炎进行了以手术治疗为中心的综合治疗．其中鼻内镜手术24例,柯-陆氏手术7例,术前、术后进行抗生素、皮质类固醇激素和抗真菌药物治疗。结果 术后均随访1年以上,无手术并发症发生．采用鼻内镜手术的患者无复发．3例采用柯-陆氏手术治疗的患者复发行二次手术。结论 本研究表明鼻内镜外科手术对变应性真菌性鼻窦炎是一种有效的微创治疗手段．手术结合内科用药对变应性真菌性鼻窦炎的治疗具有良好的效果。     

Preoperative diagnosis of allergic fungal sinusitis

OBJECTIVES/HYPOTHESIS: 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. STUDY DESIGN: Prospective, comparative study. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

变应性真菌性鼻窦炎的临床观察

目的 :探讨变应性真菌性鼻窦炎 (AFS)的诊断及治疗。方法 :8例AFS患者均行鼻内窥镜手术、激素治疗及抗真菌药物冲洗术腔。结果 :随访 13～ 4 0个月 ,2例复发 ,再次接受同样治疗 ,现仍在随访中。结论 :AFS的症状主要表现为变应性鼻炎的症状及骨质吸收 ,需要鼻内窥镜手术、激素及抗真菌药物等综合治疗。AFS易复发 ,长期随访很重要     

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. Laryngoscope, 108:1485–1496, 1998     

Increasing diagnostic yield in allergic fungal sinusitis

Diagnosis of allergic fungal sinusitis (AFS) in patients who present with rhinosinusitis and polyposis is based upon certain clinical, histopathological and mycological histopathological criteria are the demonstration of fungal hyphae in allergic mucin and absence of tissue invasion in the excised polyps. Previous reports have indicated difficulty in demonstrating fungal hyphae on histological examination in up to 75 per cent of cases. Analysis of a series of 25 patients with AFS, suggested methods to ensure demonstration of fungal hyphae and thus increase diagnostic yield in cases with suspected AFS. criteria. Specific diagnostic     

IgE‐mediated fungal allergy in allergic fungal sinusitis

This review will address the current knowledge of the pathogenic mechanisms in allergic fungal sinusitis (AFS) and the basis for the current classification of a subgroup of chronic rhinosinusitis patients. Special attention is directed to the role of immunoglobulin E (IgE)‐mediated fungal allergy in the pathogenesis of AFS. Concepts relating to the mucosal inflammatory response are introduced, as a knowledge of the reactions of the sinus mucosal cells can lead to a better understanding of the mechanisms perpetuating and maintaining the chronic inflammation. Laryngoscope, 2009     

Rhinitis caseosa, nasal cholesteatoma and allergic fungal sinusitis

The recently described Syndrome of Allergic Fungal Sinusitis (AFS) has many similarities with the previously described entity of rhinitis Caseosa (synonym-Nasal Cholesteatoma). 28 patients treated over a 6 year period with a diagnosis of rhinitis caseosa/nasal cholesieatoma have been retrospectively reviewed with regard to their clinical and radiological features, operative findings and microbiologic and histopathologual features. All cases presented with nasal obstruction and nasal polyposis. CT scanning indicated intracranil extension and intra-orbital extension m 9 cases each. Surgical debridetnent with establishment of sinus drainage led to the universal initial relief of symptoms in all cases. 26 of 28 cases have remained free of recurrence on prolonged follow-up (minimum follow-up one year). Despite these cases demonstrating clinical, radiologital, morphological and histological similarities with the Syndrome of Allergic Fungal Sinustitis, in only 2 cases was a fungal aetiology confirmed by history. The clinical syndrome of “Rhinitis Caseosa” is described and its relationship with the Allergic Fungal Sinusitis (AFS) syndrome and the “AFS-hke” Syndrome explored.     

Clinical presentation of allergic fungal sinusitis in children

OBJECTIVE: To compare the differences in the clinical and radiographic presentation of allergic fungal sinusitis in children and adults. STUDY DESIGN: Retrospective chart and computed tomography review. METHODS: The settings included a tertiary care children's hospital, adult academic private hospital, and academic affiliated county hospital. All patients with documented allergic fungal sinusitis who underwent computed tomography evaluation and had surgical treatment of their disease from 1988 to 1999 were included in the study. In total, 151 patients aged 5 to 75 years; 44 of these patients were less than or equal to 17 years of age (children) and 107 were greater than 17 years of age (adults). Main outcome measures included 1) the presence of obvious bony facial abnormalities on presentation, 2) bilateral or unilateral sinus disease on presentation, 3) the presence of asymmetrical disease on presentation, 4) the presence of bony extension on computed tomography scan, and 5) type of fungus present. RESULTS: Fifteen of 36 (42%) pediatric patients and 10 of 103 (10%) adult patients had obvious alteration of their facial skeleton (proptosis, telecanthus, or malar flattening) on presentation (P <.05). Proptosis was the most common facial abnormality in both groups and was seen more often in children (8 of 36 [22%]) than in adults (9 of 103 [9%]) (P <.05). Twenty-eight of 40 (70%) pediatric patients and 37 of 100 (37%) adult patients presented with unilateral sinus disease (P <.05). Thirty-five of 40 (88%) pediatric patients and 58 of 100 (58%) adults presented with asymmetrical disease (P <.05). Computed tomography scans showed that 10 of 40 (25%) pediatric patients and 23 of 100 (23%) adult patients had bony erosion with extension of disease into surrounding structures (P >.05). Cultures from both adults and children showed mainly Bipolaris and Curvilaria species in equal amounts (P >.05). Adults had a greater incidence of Aspergillus species. CONCLUSIONS: Presentation in pediatric patients with allergic fungal sinusitis is different from that in adults, with children having obvious abnormalities of their facial skeleton, unilateral sinus disease, and asymmetrical disease more often. Findings on computed tomography scan show an equal amount of bony erosion with extension of disease. The types of fungus cultured in the sinus cavities are similar in both groups.     

变应性真菌性鼻窦炎的诊断与治疗体会

目的 探讨变应性真菌性鼻窦炎(AFS)的诊断及治疗方法.方法 回顾性分析16例经术后病理诊断证实AFS的临床表现、实验室检查、影像学表现、手术方法及术后综合治疗.结果 随访2～4年,治愈14例(占87.5%),显效1例(占6.25%),无效1例(占6.25%).结论 AFS的诊断主要依据CT中多个鼻窦腔实变膨胀,伴有弥散匍行状或云雾状高密度影,阴影周边为软组织影,术后病理组织示大量嗜酸性粒细胞浸润,并可见Charcot-Leyden晶体.手术关键纠正鼻腔鼻窦结构异常、彻底开放病变鼻窦、清除变应性粘蛋白,术后予免疫治疗、抗真菌治疗及鼻腔冲洗.     

变应性真菌性鼻窦炎CT影像特征

目的回顾性总结变应性真菌性鼻窦炎CT影像表现,并与手术中所见比较,探讨其CT影像特征及其在诊断中的参考作用。方法收集21例确诊为变应性真菌性鼻窦炎患者的CT影像资料。男17例,女4例;年龄15岁～50岁。鼻窦CT扫描采用骨窗和软组织窗扫描。术前行鼻内镜检查、皮肤点刺变态反应皮试、总IgE及鼻分泌物嗜酸粒细胞涂片检查。手术中记录鼻窦和鼻腔病变且与CT影像对照。术后行组织病理学检查和真菌涂片＋培养。结果鼻内镜检查见所有病例鼻腔单发或多发半透明粉白色息肉,周围稀薄黄色或黏白色分泌物。9例11侧鼻腔可见果酱样黄褐色黏着分泌物。鼻窦CT扫描提示单侧鼻窦发病10例（10侧）,双侧病变为11例（22侧）;单侧或双侧病变全组鼻窦均受累;鼻窦腔散在均匀高密度影,呈毛玻璃样特征,周边为软组织影,3例4侧颅底骨质吸收,1例颅内侵犯。20例行鼻内镜手术,1例行双冠经路＋鼻内镜手术。术中见17例窦腔有果酱样黄褐色黏着分泌物（黏蛋白）,4例窦腔为褐绿色泥样分泌物。随访6个月至7年,治愈14例,好转7例,其中3例术后2年再手术。结论鼻窦CT扫描显示鼻窦腔内片状毛玻璃样高密度影,可伴骨质吸收或侵袭性生长,为变应性真菌性鼻窦炎具有诊断意义的影像检查特征。     

Management of allergic fungal sinusitis with intracranial spread

Allergic fungal sinusitis (AFS) is a form of paranasal nasal disease if not managed early often involves bone destruction and extension into the orbit and anterior skull base. We present our study of patients with AFS with intracranial, exdradural extension. This study includes our experience of 26 patients with the histological and immunological diagnosis of AFS based on findings of branching septate fungi interspersed with eosinophilic mucin and Charcot-Leyden crystals without fungal invasion of soft tissue, with intracranial extension. All had erosion of bone, which was observed on computerized tomography (CT) scans, extending intracranially and eight had disease that additionally involved the lamina papyracea. The average age of patients in this study was 25 years (range 9–46). There were 20 male and 6 female patients. All patients were immunocompetent. Skin test against aspergillin showed all patients had Type 1 hypersensitivity. All patients underwent transnasal and/or transmaxillary endoscopic approaches for debridement and eight underwent orbital decompression. No patient underwent craniotomy for removal of intracranial extradural disease. No patient had a cerebrospinal fluid leak. Postoperatively, all 26 were treated with a course of corticosteroids. The follow-up period ranged from 2 to 5 years. We conclude AFS is a unique form of fungal disease that might mimic anterior skull base and paranasal sinus tumors. Most cases can be successfully managed with transnasal and/or transmaxillary endoscopic techniques.     

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.