Search

A review of the treatment of allergic and invasive fungal sinusitis, as well as a presentation of the first recorded case of a conversion from allergic fungal sinusitis (AFS) to chronic granulomatous invasive sinusitis and the fourth case of invasive fungal sinusitis associated with Curvularia. This immunocompetent patient suffering from chronic AFS converted after repeated high-dose steroid tapers and noncompliance. AFS may present atypically and should be suspected even in immunocompetent patients with sinus disease who report new onset pain and neurologic symptoms. Clinicians should consider the potential complications associated with repeated systemic steroid administration. Laryngoscope, 129:2447-2450, 2019.

BACKGROUND Ear symptoms are common among patients presenting to a rhinology clinic. Validated inventories are available for patient quality-of-life in sinonasal disease and Eustachian tube dysfunction (ETD). This study sought to determine the extent of ETD symptoms, using validated metrics, in a large population of patients presenting to a tertiary rhinology clinic. METHODS Seven-item Eustachian Tube Dysfunction Questionnaires (ETDQ-7) and 22-item Sino-Nasal Outcome Tests (SNOT-22) were prospectively collected from 492 patients treated in a tertiary rhinology clinic. Patient diagnoses were retrospectively determined from the medical record. Correlation between reported SNOT-22 and ETDQ-7 scores were analyzed, in addition to the number of patients meeting the criterion score for ETD. RESULTS A total of 213 patients reported mean ETDQ-7 scores >2.1, consistent with a diagnosis of ETD. Overall SNOT-22 scores were strongly correlated with ETDQ-7 scores (r = 0.679, p < 0.001). The SNOT-22 ear subdomain was very strongly correlated with the ETDQ-7 score (r = 0.847, p < 0.001), while there was a moderate correlation with the SNOT-22 rhinologic subdomain (r = 0.486, p < 0.001). Patients with allergic fungal sinusitis had decreased ETDQ-7 scores compared to patients with other rhinologic diagnoses (p = 0.010). CONCLUSION Symptoms of ETD are common in patients treated in a rhinology clinic, with 43.3% of patients reporting symptom scores consistent with a formal diagnosis of ETD. Increased SNOT-22 scores are correlated with increased ETDQ-7 scores, even when only the SNOT-22 rhinologic subdomain is considered. Patients presenting for treatment of rhinologic symptoms likely have an increased prevalence of otologic symptoms and ETD.

A case of allergic fungal sinusitis (AFS) due to Schizophyllum commune was reported. The pathogen was identified using molecular bioanalysis. The patient underwent the functional endoscopic sinus surgery followed by the radical maxillary sinusotomy with canine fossa trephine. This case suggested that complete surgery allowed optimal disease clearance for AFS caused by Schizophyllum commune. Keywords: Sinonasal infection, Surgery, Molecular typing

Background Mold pathogens are a leading cause of chronic rhinosinusitis. Successful isolation of mold on culture is helpful in establishing a diagnosis and guiding therapy. Though mucolytic agents are commonly used in European countries, they are not part of everyday use in North America. In this case-control prospective study, we investigated the yield of fungal culture before and after treatment of sinus aspirates with the mucolytic agent dithiothreitol in a United States hospital. Methods Over a 5-month period during 2011–2012, 359 sinus aspirates from 294 patients with symptoms suspicious for chronic sinusitis or allergic fungal sinusitis were collected. Aspirates were cultured on fungal medium before and after treatment with dithiothreitol. Results Of the 359 pairs of cultures, 62 (17.3%) demonstrated mold growth on at least 1 of the plates, 9 (14.5%) of which grew more than 1 species of mold. A total of 75 molds were identified, 41 (54.7%) of which were successfully cultured only when the mucus was pretreated with dithiothreitol (p < 0.0001). Quantitatively, more colonies grew from dithiothreitol-treated mucus than from direct-inoculation (p < 0.0001). Conclusion This study confirms improved recovery of mold from sinus cultures after pretreatment of samples with dithiothreitol. Further studies are needed to correlate these findings with clinical outcome.

BACKGROUND AND PURPOSE This case involves a common disease, allergic fungal sinusitis (AFS), with the uncommon complication of intracranial abscess. Although AFS is known to result in bone erosion, invasive complications are rare. METHODS The clinical and pathologic information were reviewed. A literature review was performed to clarify the clinical, radiologic, and pathologic features of AFS. RESULTS The clinical and radiographic presentations were typical for AFS, including the relatively common complication of sinus wall erosion. Follow-up imaging demonstrated spread of fungal disease into the adjacent masticator space and intracranial spread by foramen ovale. CONCLUSION This case illustrates the importance of identifying AFS and describing findings such as sinus erosion that may alter management. In this example, knowledge of the altered anatomy and potential for mucosal injury may facilitate surgical planning and decrease the likelihood of future complications.

An immunoglobulin (Ig)E-mediated allergic pathogenesis is presumed in allergic fungal sinusitis (AFS), yet extensive polyps and eosinophilic mucus (EM) in the paranasal sinuses may also occur in the absence of allergy. Although a noninvasive fungal pathogenesis is presumed in all chronic rhinosinusitis with EM (EMCRS), fungal-specific nonallergic immune responses have not been thoroughly investigated. We tested the hypothesis that there is a fungal-specific humoral response in EMCRS and that it is not confined to IgE.EMCRS patients were prospectively stratified into subgroups based on the presence or absence of fungi within EM and of fungal-specific systemic IgE. There were 12 AFS, 5 AFS-like, 8 nonallergic fungal eosinophilic sinusitis (NAFES), and 5 nonallergic, nonfungal eosinophilic sinusitis (NANFES) patients.Alternaria alternata and Aspergillus fumigatus-specific serum IgE, IgG, IgM, and IgA was measured by enzyme-linked immunosorbent assay and compared with strictly defined healthy and disease-control groups.Fungal-specific IgG (Alternaria alternata P = .0002; Aspergillus fumigatus P = .004), and IgA levels (Alternaria alternata P = .0016; Aspergillus fumigatus P = .002) were higher in EMCRS compared with healthy volunteers but not with disease controls. Fungal-specific IgG3 levels were significantly elevated in all the EMCRS subgroups compared with controls for either fungal antigen (P.0001). Importantly, fungal-specific IgE levels were not significantly different between fungal-allergic EMCRS and disease controls.Fungal-specific immunity characterized by serum IgG3 and not IgE, distinguished the EMCRS subgroups from control groups regardless of the presence of fungus within EM or of systemic fungal allergy. Fungal-specific IgE responses in fungal-allergic EMCRS were no different to those in fungal-allergic controls, thus challenging the presumption of a unique pathogenic role of fungal allergy in "allergic fungal sinusitis."

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.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.Advanced AFS may be complicated by histologic evidence of tissue invasion.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.

Objective Test performance of a new prototype microdebrider blade. The commercially-available, standard 4.0-mm Medtronic straight Tricut blade was tested against the new, prototype 4.3-mm Medtronic straight Quadcut blade in experimental surgical conditions utilizing both a nasal polyp (NP) analog (raw oysters) and an allergic fungal sinusitis (AFS) analog (minced beef cat food). Methods Both sides of 5 thawed, fresh-frozen cadaver heads were utilized for NP analog removal. AFS analog was removed out of specimen containers. A total of 10 paired data points were collected for time of surgical removal and number of clogs comparing the 2 blades. Results For simulated AFS debris, the prototype clogged less than the standard blade (0 vs 4.5, p < 0.0001). There were no clogs noted for either blade with the NP analog. Time for debris eradication was significantly improved for both AFS analog (147.4 vs 262.0 seconds, p < 0.0001) and NP analog (43.7 vs 112.1 seconds, p < 0.0001). Conclusion The prototype blade offers faster debris and polyp removal and clogs less in the setting of allergic fungal debris. As the new blade is faster and more aggressive, introduction into a surgical setting should be guarded with an appropriate degree of caution. © 2011 ARS-AAOA, LLC.

Objectives:Allergic fungal rhinosinusitis (AFRS) is well known to expand and to extend to the surrounding structures like the orbit and the brain; however, it has not been reported to extend to the infratemporal fossa (ITF). Because of the difficulty of accessing the ITF, we report our experience over 5 years.Methods:One hundred one patients with AFRS were operated upon by the author between 2008 and 2013.Results:All of these patients had preoperative computed tomography scans (CTs), and all but 2 had postoperative CT of the paranasal sinus. Twelve had expansion or extension of the disease into the ITF: 8 males and 4 females, their ages ranged from 10 to 34 years with mean of 20.4 years. Four of them were children below 15 years of age. Three patients had bilateral disease and 9 had unilateral sinus involvement. Seven cases had expansion of the posterior wall of the maxillary sinus into the ITF, which was unilateral and mil; however, extension from the sphenoid sinus was more extensive in most of the case...

Objective: Sixty patients with a diagnosis of allergic fungal sinusitis were studied. The objective was to show whether, after initial surgical removal of allergic mucin and polyps, immunotherapy decreases re-operation rates and office visits that require medical intervention. Study Design and Setting: Sixty patients with adequate follow-up for at least 1 year were evaluated: 24 patients who did not receive immunotherapy and 36 patients whose treatment included postoperative immunotherapy. Results: The re-operation rates were 33.0% in those not receiving immunotherapy versus 11.1% in the treated group. Furthermore, the total number of postoperative office visits that required medical therapy decreased from 4.79 per patient to 3.17 with the addition of immunotherapy. Conclusion/Significance: These results indicate that immunotherapy is a beneficial part of the overall treatment regimen for allergic fungal sinusitis. (Otolaryngol Head Neck Surg 2001;125:487-90.)

Since August 1994, we have treated patients with histologically proven allergic fungal sinusitis with surgery followed by immunotherapy, employing fungal and nonfungal antigens to which hypersensitivity has been demonstrated. Our results continue to be encouraging. Not only have we encountered no indication that fungal immunotherapy has worsened these patients' condition or caused a recurrence of disease, we have confirmed dramatic improvement in these patients compared with the generally accepted course of this disease. Of 11 patients who have received immunotherapy for 1 to 3 years (mean 28 months), none has required regular or frequent treatment with a single brief course of systemic steroids, and only three are receiving topical nasal steroids. No repeat surgeries for recurrent allergic fungal sinusitis have been required in the treatment group. This combination of surgery and immunotherapy has continued to prove beneficial, and we urge others to consider this approach to therapy.

Since August 1994 we have followed a protocol of treating patients with histologically proven allergic fungal sinusitis with surgical extirpation of the involved sinuses, followed by immunotherapy using both fungal and nonfungal antigens to which hypersensitivity is demonstrated by in vitro and skin testing methods. Despite predictions to the contrary, we have encountered no evidence that these injections have worsened the condition of any patients. Rather, we have noted a marked decrease in nasal crusting in all patients, with a minimum amount of recurrent polypoid mucosa and a lessened or absent requirement for corticosteroids (systemic or topical). Two patients treated with immunotherapy required systemic corticosteroids and subsequent revision surgery for residual disease that was present before the start of immunotherapy, and they have done well since. Our experience indicates that the triad of adequate surgery, frequent follow-up and medical management, and immunotherapy with relevant fungal and nonfungal antigens represents an effective means of treating patients with allergic fungal sinusitis. Nevertheless, an even longer period of study will be necessary to provide the final answer regarding the role of immunotherapy in the treatment of allergic fungal sinusitis. (Otolaryngol Head Neck Surg 1997;117:367-71.)

The objective of this study was to describe CT and MR findings in patients with allergic fungal sinusitis (AFS). CT and MR images were examined from 10 patients with histologically proven AFS. All patients demonstrated CT evidence of central sinus high attenuation and T2-weighted MR signal void corresponding to surgically proven areas of thick inspissated allergic mucin. AFS is a distinct clinical entity with a highly specific radiographic appearance based on CT and MRI.

Recommendations to withhold immunotherapy with fungal antigens from patients with allergic fungal sinusitis (AFS) have been based primarily on retrospectively reviewed, anecdotal case reports and theoretical considerations. A study that was approved by the investigational review board of our institution is ongoing in our department to administer immunotherapy with relevant fungal antigens to patients with histologically proven AFS. After 1 year, no instances of worsening of symptoms as a result of this therapy have been observed. Objective measurement of improvement has been difficult, but our initial clinical impression is that this treatment regimen has resulted in significant reduction in the reaccumulation of crusts and allergic mucin within the sinuses, has led to a reduction in the use of topical nasal steroids, and has made systemic steroid therapy unnecessary, thereby improving the quality of life of the patient. A further study of immunotherapy for patients with AFS is recommended, and suggestions for modification of the current protocol are presented.

Allergic fungal sinusitis is a benign noninvasive sinus disease related to a hypersensitivity reaction to fungal antigens. A wide variety of fungal agents has been implicated, with the vast majority belonging to the Dematiaceae family. Allergic fungal sinusitis should be suspected in any atopic patient with refractory nasal polyps. Sinus computed tomograms and magnetic resonance imaging findings can be quite distinctive, but not diagnostic. Diagnosis requires histopathologic examination, which shows characteristic allergic mucin. Hyphae can be demonstrated on special fungal stains or confirmed by a positive fungal culture. At surgery, the diagnosis should be considered if thick, tenacious allergic mucin is encountered in the atopic patient with nasal polyps. Fungal cultures should then be obtained, and the pathologist alerted to the possible diagnosis of allergic fungal sinusitis. Current recommendations for therapy include conservative but complete exenteration of all allergic mucin. This can often be accomplished endoscopically. Adjunctive short-term systemic steroids are often helpful, and nasal steroid sprays should be continued long term. The length and dose of steroid therapy is controversial. Persistence of allergic fungal sinusitis with recurrence of sinonasal symptoms is common, particularly when there has been incomplete eradication of allergic fungal mucin. Even when the patient is clinically disease free, recurrence can occur, presumably from reexposure to fungal antigens. Therefore close clinical, endoscopic, and radiographic follow-up is important.

Objective: 1) To evaluate the clinical and radiological profile of massive allergic fungal sinusitis (AFS) in children. 2) To evaluate the efficacy of external open sinus surgery for recurrent massive AFS in children.Method: Retrospective review of clinical and radiological records at tertiary care university hospital. Twelve pediatric patients (age 9-15 years, mean 13.2 years) of recurrent massive AFS who had skull-base erosion, intracranial extension with unilateral or bilateral intraorbital involvement on CT scan were included in study. All patients had undergone multiple unsuccessful endonasal operations (range, 3-5; mean, 3.8). Patients were operated by bilateral lateral rhinotomy and transfrontal approaches (3), transantral endoscopic approach (7), and combined lateral rhinotomy and transnasal approach (2). All patients received postoperative antibiotics and steroids. Postoperative follow-up was done, and symptoms were evaluated (range, 14-24 months; mean 17.5 months).Results: Nasal obstruction and ...

Objective: 1) Identify acute and chronic indications for orbital and/or optic nerve decompression. 2) Review known techniques for endoscopic orbital decompression. 3) Evaluate the necessity to include inferior orbital wall/orbital floor. 4) Compare and contrast the endoscopic technique in comparison to various open methods.Method: Retrospective review of all patients that underwent endoscopic orbital decompression procedures between 2009 and 2011. Data analysis included review of perioperative clinical findings, operative technical details, radiology data, and outcomes.Results: A total of 15 orbital decompressions were performed. All patients underwent endoscopic medial orbital wall decompression, 2 included the orbital floor. The majority of the patients had allergic fungal sinusitis as their primary diagnosis for surgical indication (n = 7, 47%). Neoplasms (n = 5, 33%) and Graves disease (n = 3, 20%) were the remaining diagnoses. Restricted ocular motility, proptosis, and diplopia were the most common p...

Objective: 1) Report a very unusual presentation of allergic fungal sinusitis. 2) Alert the practicing clinician to consider allergic fungal sinusitis in the differential diagnosis of unilateral or bilateral cranial neuropathies.Method: We report a case from 2010 of a 39-year-old man presenting initially with bilateral abducens nerve palsy and subsequently found to have allergic fungal sinusitis with skull base erosion. The patient underwent an endoscopic approach and resection of the lesion, which extended intracranially into the epidural space.Results: An endoscopic image-guided resection of the skull base lesion was successfully performed in the patient, with intraoperative findings consistent with allergic fungal sinusitis. Pathology and microbiology results revealed aspergillus fumigatus. Postoperatively the patient recovered well with complete resolution of his left abducens nerve function and no CSF leak. AFS, reportedly present in as many as 5%-10% of patients with chronic rhinosinusitis, can pres...

Objective: 1) Examine the efficacy of FESS combined with aggressive postoperative medical management in the treatment of allergic fungal sinusitis (AFS). 2) Determine prognostic factors associated with disease recurrence and the need for subsequent revision surgery in a population of AFS patients.Method: A retrospective case control study examined demographic and disease-related characteristics and adjuvant therapies in patients undergoing combined surgical and medical treatment of AFS in a single tertiary academic center. Exclusion criteria included follow-up of less than 6 months. The dependent variable was revision surgery. Average follow-up was 29.4 months.Results: Eighty consecutive AFS patients from 2002 to 2009 were identified and 62 patients did not require revision surgery (78%).Conclusion: AFS can be effectively controlled with multimodality therapy. Compliance with postoperative medical therapy and topical steroid use are prognostic factors associated with treatment success, decreasing the rate...

Although the treatment of allergic fungal sinusitis with specific immunotherapy after surgical intervention has proved successful, the question of what happens when such injections are discontinued remains unanswered. In this initial, admittedly small series, no recurrence has been noted in follow-up of 7 to 17 months. (Otolaryngol Head Neck Surg 2000;122:104-6.)

RAST tests have traditionally been considered less sensitive than skin tests during investigation of atopy involving molds. This has been attributed to technical problems such as difficulty in binding the mold antigen to the carrier substrate. Ten patients with proven allergic fungal sinusitis were evaluated for sensitivity to 11 important molds by both RAST and dilutional intradermal testing. A predictable correlation between RAST and skin test scores was observed in many, but not all, cases. Most often this disparity was in the form of greater sensitivity indicated by skin testing than by RAST, sometimes differing by as many as 3 classes. The lack of concordance was not confined to testing for the fungi cultured from the sinuses, nor was it more or less pronounced in the case of dematiaceous fungi. The most likely causes for the disparity noted in this series are subtle differences in antigens used in skin test material and for RAST standards. Skin tests allow for evaluation of delayed and late-phase reactions, a measurement not possible by specific IgE testing with RAST. Delayed skin test reactions were not noted in this series of patients. An additional important finding was the sensitivity of patients with allergic fungal sinusitis to virtually every fungal antigen to which they were tested.

ObjectiveTo describe current indications, sinonasal pathologies, and outcomes of endoscopic sinus surgeries (ESS) in children.MethodsRetrospective chart review of children that underwent ESS at a children's tertiary care facility from July 2004 to June 2007 was performed. Demographic data, clinical profiles, surgical procedures including revisions, and complications were analyzed.Results117 ESS were performed on 88 children (mean age 9.6 years) and 4 adults; 64 were male. The most common indications for ESS in descending order were: chronic rhino-sinusitis (CRS) (n=29), subperiosteal periorbital abscess (n= 20), sinonasal neoplasm (n= 11), intracranial complication from acute sinusitis (n=8), CRS with cystic fibrosis (n=8), complicated acute sinusitis (n=6), allergic fungal sinusitis (n=5), antrochonal polyps (n=2), invasive fungal sinusitis (n=1), and other pathologies (n=2). 21 children underwent an average of 2.2 sinus procedures. Majority of revisions were on patients with tumors (46%), allergic funga...

One of the commonly held concepts regarding allergic fungal sinusitis is that patients with this disorder also demonstrate allergy to other inhalants. However, few published investigations have confirmed this. In this study serum from 16 consecutive patients with histologically proven allergic fungal sinusitis was tested with a seasonal and a perennial radioallergosorbent microscreen disk. The seasonal radioallergosorbent microscreen combines on one disk antigens for two grasses, two weeds, and two trees, and the perennial disk contains Alternaria and dust mite antigens. Total immunoglobulin E was also determined for each sample. Fifteen of the 16 samples demonstrated a radioallergosorbent class II or greater response to one of the two disks, and 11 showed a radioallergosorbent class II or greater response to both. The total immunoglobulin E level was greater than 100 units/ml in 14 samples (> 1000 in 4 cases) and 97 units/ml in another. This study addresses the presence of inhalant allergy in patients with allergic fungal sinusitis previously described in case reports. The results support the concept that allergic fungal sinusitis is a true allergic (rather than infectious) disease. (OTOLARYNGOL HEAD NECK SURG 1995;113:721-3.)

Educational objectives: To categorize fungal sinusitis along an immunologic spectrum and direct therapy on the basis of whether fungus is invasive, indolent, a mycetoma, saprophytic, or allergic fungal sinusitis (AFS) and to recognize clinical aspects of AFS and be aware of pitfalls in the diagnosis, including allergic mucin without fungus.