Search

Objectives: Allergic fungal rhinosinusitis (AFRS) often results in expansion of disease beyond the paranasal sinuses, which may put important structures, such as the anterior ethmoid artery (AEA) or lateral lamella of the cribiform, at risk of injury during endoscopic sinus surgery (ESS). This study aims to compare the AEA to skull base (AEA-SB) length in patients with AFRS versus chronic rhinosinusitis with nasal polyps (CRSwNP), as well as additional anatomic variants. Methods: A single institutional retrospective chart review of patients undergoing ESS for AFRS and CRSwNP was performed. AEA-SB length were compared between the 2 groups. Other anatomic variants, including Keros measurement and presence of supraorbital ethmoid air cells (SOEC), concha bullosa (CB), sphenoethmoidal, and infraorbital ethmoid cells were measured and compared between the 2 groups. Results: Twenty-one patients were included in each cohort. The AFRS group was younger in age (P =.015) and had a significantly longer AEA-SB length (P =.014) compared to the CRSwNP group. No significant differences were observed between the 2 groups regarding Keros measurement, presence of concha bullosa, infraorbital ethmoid, sphenoethmoidal, or SOEC. No association was seen between AEA-SB length and Keros class in either group. Conclusions: AFRS harbors anatomical differences when compared to CRSwNP, with the former associated with a longer AEA-SB length. This key difference should be considered in preoperative planning to prevent injury to the AEA in patients undergoing ESS for AFRS. [ABSTRACT FROM AUTHOR]

Background: Fungal rhinosinusitis is subdivided into two subtypes, invasive and noninvasive variants, with allergic fungal rhinosinusitis (AFRS) being the most prevalent noninvasive variant. The most common clinical features of AFRS are nasal polyposis, rhinorrhea, facial pressure, and periorbital edema. Objective: This study aimed to report a rare clinical presentation and serious complications of AFRS. Method and result: The patient was presented to the Otorhinolaryngology Department of Qatif Central Hospital, Eastern Region, Saudi Arabia. We reported a rare presentation of a patient diagnosed with untreated AFRS complicated by basilar artery thrombosis. The patient was urgently managed with endoscopic sinus surgery, postoperative antifungal, and local nasal steroids. Conclusion: Allergic fungal rhinosinusitis is a chronic disorder associated with significant morbidity that requires early diagnosis and management. The treatment protocol was based on surgical debridement of the paranasal sinuses from the fungal material and postoperative steroid therapy. Allergic fungal sinusitis with granuloma was more aggressive and needed to be treated cautiously by adding antifungal treatments. [ABSTRACT FROM AUTHOR]

Introduction: Allergic fungal rhinosinusitis (AFRS) is a severe phenotype of chronic rhinosinusitis with nasal polyposis (CRSwNP), characterised by localised and exaggerated type 2 inflammation. While fungal antigenic stimulation of unregulated Th2‐mediated inflammation is the core pathophysiological mechanism, the direct and synergistic role of bacteria in disease modification is a pervasive hypothesis. We set out to define the microenvironment of AFRS to elucidate virulent organisms that may be implicated in the pathophysiology of AFRS. Methodology: We undertook a cross‐sectional study of AFRS patients and non‐fungal CRSwNP patients. Demographics, disease severity, culture and microbiome sequences were analysed. Multimodality microbiome sequencing included short‐read next‐generation sequencing (NGS) on the Illumina Miseq (16S rRNA and ITS) and full‐length 16S rRNA sequencing on the Oxford Nanopore Technologies GridION (ONT). Results: Thirty‐two AFRS and 29 non‐fungal CRSwNP patients (NF) were included in this study. Staphylococcus aureus was the dominant organism cultured and sequenced in both AFRS and NF groups (AFRS 27.54%; NF 18.04%; p =.07). Streptococcus pneumoniae (AFRS 12.31%; NF 0.98%; p =.03) and Haemophilus influenzae (AFRS 15.03%; NF 0.24%; p =.005) were significantly more abundant in AFRS. Bacterial diversity (Shannon's index) was considerably lower in AFRS relative to NF (AFRS 0.6; NF 1.0, p =.008). Aspergillus was the most cultured fungus in AFRS (10/32, 31.3%). The AFRS sequenced mycobiome was predominantly represented by Malassezia (43.6%), Curvularia (18.5%) and Aspergillus (16.8%), while the NF mycobiome was nearly exclusively Malassezia (84.2%) with an absence of Aspergillus or dematiaceous fungi. Conclusion: A low diversity, dysbiotic microenvironment dominated by Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae characterised the bacterial microbiome of AFRS, with a mycobiome abundant in Malassezia, Aspergillus and Curvularia. While Staphylococcus aureus has been previously implicated in AFRS through enterotoxin superantigen potential, Streptococcus pneumoniae and Haemophilus influenzae are novel findings that may represent alternate cross‐kingdom pathophysiological mechanisms. [ABSTRACT FROM AUTHOR]

Allergic fungal rhinosinusitis (AFRS) shares similarities with eosinophilic chronic rhinosinusitis (ECRS), both characterized by intractable nasal polyps. The key distinction lies in the presence of fungal infection within the nasal cavity. While ECRS nasal polyps are known for significant infiltration of M2 macrophages and eosinophils, as well as an increase in high endothelial venule (HEV)-like vessels, these features are less commonly reported in AFRS. This study compared clinicopathological findings between AFRS (n =10), ECRS (n =12), and non-ECRS (n =10) patients' nasal polyps using immunohistochemical analysis for CD163 and CD68 to assess the M2/M1 macrophage ratio, and peripheral lymph node addressin (PNAd) and CD34 to evaluate the proportion of HEV-like vessels. AFRS showed a significantly higher number of CD163-positive M2 macrophages and an increased M2/M1 ratio compared with ECRS. However, the percentage of HEV-like vessels and the number of eosinophils infiltrating the nasal polyps were similar in both AFRS and ECRS. The observed increase in M2 macrophages in AFRS nasal polyps is presumed to be induced by fungal infection in the nasal cavity, in comparison with ECRS. These results highlight the distinctive immunological profiles of AFRS and ECRS, emphasizing the role of macrophage polarization in their pathogenesis. [ABSTRACT FROM AUTHOR]

Background: Aspergillus is one of the most common pathogens causing fungal allergy in the respiratory tract. Serum Aspergillus fumigatus- specific immunoglobulin G (Af-sIgG) levels have been used as a biomarker for the diagnosis and treatment response monitoring in airway allergic diseases such as allergic bronchopulmonary aspergillosis and allergic fungal rhinosinusitis. However, its role in common primary chronic rhinosinusitis (CRS) was unclear. Objective: This study aims to evaluate whether serum Af-sIgG level could serve as a biomarker for the disease presentation of primary CRS. Methods: We obtained serum Af-sIgG levels from patients diagnosed as bilateral primary CRS refractory to medical treatment and evaluated the correlations between serum Af-sIgG levels and disease severity in patients with type 2 (T2) and non-T2 CRS. Results: Patients with T2 CRS exhibited significantly higher serum Af-sIgG levels than non-T2 CRS patients. The cut-off value of serum Af-sIgG in T2 CRS was 20.9 mg/L, with an odds ratio of 3.8 (95% CI 1.17-12.20, P =.026). Furthermore, serum Af-sIgG levels were positively correlated with symptom scores evaluated by the Sino-Nasal Outcome Test-22 (SNOT-22) scores in T2 patients (P =.009). While stratified by SNOT-22 total scores, patients with severe disease had higher serum Af-sIgG levels only in T2 CRS (P =.034). In individual domains of SNOT-22 analysis, serum Af-sIgG levels showed a significant correlation with "ear/facial" symptom scores in the T2 group (P <.001). Conclusions: Serum Af-sIgG levels may serve as a supplementary objective biomarker that correlates with identification and subjective measurements of T2 CRS, and may be associated with symptoms arising from Eustachian tube dysfunction. [ABSTRACT FROM AUTHOR]

The article discusses an algorithm for managing primary diffuse chronic rhinosinusitis (CRS) developed by a team of experts from various institutions. The classification of CRS has evolved, impacting management strategies, with localized disease often treated surgically and diffuse disease requiring anti-inflammatory treatment. The development of biologics has been a breakthrough for CRS with nasal polyps, particularly type2 CRS, offering potential disease-modifying effects. The article emphasizes the importance of precision medicine, endotyping patients, and considering various treatment options based on individual characteristics and responses. [Extracted from the article]

This study aimed to comprehensively investigate the prevalence of ABPA and AFRS, scrutinize existing diagnostic criteria and immunoassays, pinpoint their limitations, highlight ABPA as an occupational health implication, and identify suggestive measures to improve ABPA diagnosis in the context of Occupational Health Nursing and primary healthcare. The data sources such as PubMed, Health and Safety Science Abstracts, OSH Update, Medline, and Google Scholar were searched. All published studies in the English language from 1990 till Oct, 2023 using Mesh terms keywords "Allergic bronchopulmonary aspergillosis," "Allergic fungal rhinosinusitis," "Signs and Symptoms," "Rapid Diagnostic Tests," "Diagnosis," "Occupational Health," "Occupational Health Nursing," "Prevalence," "Allergens" following "Boolean operators" search strategy were selected. This review succinctly covered signs, symptoms, and prevalence data concerning ABPA and AFRS. It briefly discussed existing diagnostic criteria and immunoassays, highlighted factors influencing the assay's variability, and underscored the role and scope of specific allergens toward improved, simple, and early ABPA diagnosis. ABPA as a neglected occupational health concern was emphasized, and the importance of RDTs in the context of healthcare professionals and OHNs was stated. Finally, this study suggested analyzing the impact of compromised post-pandemic immune status and the use of immunosuppressive drugs on ABPA prevalence among vulnerable communities and occupations. To conclude, global and Indian ABPA and AFRS prevalence data, factors influencing existing assay variability, and the scope of improvement in RDTs for ABPA diagnosis in the background of primary healthcare professionals and OHNs were addressed. [ABSTRACT FROM AUTHOR]

Background: Allergic fungal rhinosinusitis (AFRS) is a distinct type of chronic polypoid rhinosinusitis that affects atopic individuals. The incidence worldwide ranges from 5% to 10%, with geographic variation in epidemiology. It imposes a significant negative impact on quality of life, concomitantly generating socioeconomic losses. Failure to remove all sinus disease increases the likelihood of relapse; thus, the best outcome is achieved through coordinated medical-surgical care. The antifungal activity of itraconazole in addition to standard steroid therapy may provide greater relief to patients with AFRS following functional endoscopic sinus surgery (FESS) by decreasing the chances of recurrence and long-term use of steroids. Therefore, this study has been taken up. Aim and Objectives: The aims and objectives of the study are to evaluate the efficacy of oral itraconazole as an add-on to the standard steroid therapy in allergic fungal rhinosinusitis from baseline to 6 weeks. Materials and Methods: This study was conducted among 60 patients who underwent FESS and were administered medications postoperatively. The efficacy was measured by the sinonasal outcome test-20 score, the nasal endoscopic grade, and the Lund and Mackay score from baseline to 6 weeks. Continuous data were analyzed using the unpaired t-test, repeated measure analysis of variance, and paired t-test, whereas categorical data were analyzed using the Chi-square test. Results: Comparable efficacy was observed between the group treated with standard steroids alone and the group receiving a combination of standard steroids and itraconazole. No significant improvement was seen with oral itraconazole as an add-on therapy when compared with standard steroids at the end of 6 weeks. Conclusion: Oral itraconazole as an add-on therapy will reduce the chances of recurrence such as steroids, but in this study, there was no statistically significant reduction. The disease has a long natural course, and further follow-up is needed to establish the importance of itraconazole. [ABSTRACT FROM AUTHOR]

Eosinophilic inflammation is primarily characterized by type 2 immune responses against parasitic organisms. In the contemporary human being especially in developed countries, eosinophilic inflammation is strongly associated with allergic/sterile inflammation, and constitutes an undesired immune reaction. This situation is in stark contrast to neutrophilic inflammation, which is indispensable for the host defense against bacterial infections. Among eosinophilic inflammatory disorders, massive accumulation of eosinophils within mucus is observed in certain cases, and is often linked to the distinctive clinical finding of mucus with high viscosity. Eosinophilic mucus is found in a variety of diseases, including chronic allergic keratoconjunctivitis, chronic rhinosinusitis encompassing allergic fungal sinusitis, eosinophilic otitis media, eosinophilic sialodochitis, allergic bronchopulmonary aspergillosis/mycosis, eosinophilic plastic bronchitis, and eosinophilic asthma. In these pathological conditions, chronic inflammation and tissue remodeling coupled with irreversible organ damage due to persistent adhesion of toxic substances and luminal obstruction may impose a significant burden on the body. Eosinophils aggregate in the hyperconcentrated mucus together with cell-derived crystals, macromolecules, and polymers, thereby affecting the biophysical properties of the mucus. This review focuses on the clinically significant challenges of mucus and discusses the consequences of activated eosinophils on the mucosal surface that impact mucus and persistent inflammation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis (CRS) that has previously been associated with younger age and Black patients. However, the role of demographic and socioeconomic factors in AFRS severity remains to be fully elucidated. OBJECTIVE: The objective of this study was to determine whether demographic and socioeconomic factors are associated with incidence of AFRS, as well as with disease severity in Northern California. METHODS: A retrospective cohort study was conducted of adult patients with AFRS and CRS from 2010 to 2019. AFRS was determined by the Bent and Kuhn criteria, and severity was assessed by radiographic evidence of cranioorbital invasion and other clinical parameters. Chi-square and t-test were used to assess demographic and socioeconomic differences between AFRS and CRS cohorts, and multivariable logistic regression was used to assess risk factors for severe AFRS. RESULTS: Black patients represented 26.2% (55/210 patients) of the AFRS group and 4.9% (842/17,300 patients) of the CRS group, with pairwise comparison of race/ethnicity categories showing that the AFRS group had significantly higher proportions of Black race/ethnicity compared with other race/ethnicities (p < 0.01). AFRS and CRS groups differed significantly by age, with mean ages of 48.7 and 51.0 years, respectively (p = 0.04). There were no significant differences in gender, Medicaid status, comorbidities, and socioeconomic status measures. Multivariate logistic regression showed that Black patients had higher odds of having severe AFRS (adjusted odds ratio = 2.29; 95% confidence interval: 1.18–4.45). CONCLUSION: AFRS has a unique predilection for Black patients, and severe disease is also more likely in this population. [ABSTRACT FROM AUTHOR]

Allergic fungal rhinosinusitis (AFRS) stands out as the predominant form of fungal sinusitis, primarily attributable to a hypersensitive response to fungal invasion. AFRS Characterized by symptoms of rhinosinusitis. The expanding mass in the disease leads to bony restructuring and implicating adjacent anatomical structures. AFRS may extend beyond the sinus cavities, leading to compression of nearby structures like the orbit, optic and abducens nerves which leads to many complications such as nerve palsies and proptosis. Diagnosis of AFRS typically necessitates radiographic assessment initially, with histopathological examination serving as the confirmatory modality. The management of AFRS typically entails a multifaceted approach integrating surgical intervention alongside medical therapy. This case report illustrates a distinctive manifestation of abducens nerve palsy secondary to allergic fungal sinusitis which had dramatic improvement and resolution of the diplopia after the Endoscopic sinus surgery. Steroids and nasal saline irrigation have been prescribed post operatively to prevent the recurrence. [ABSTRACT FROM AUTHOR]

Introduction: Upper respiratory tract infections and sinusitis are more prevalent in children than in adults. Unilateral sinusitis is not uncommon disease. Our aim was to analyze the disease characteristics in children with unilateral sinusitis and compare them with those of adults. Materials and Methods: This study included 124 patients with unilateral chronic sinusitis divided according to age into two groups: pediatric group =18 years (66 cases) and adult group >18 years (58 cases). The groups were compared in terms of demographic data, side, clinical manifestations and radiological findings. Results: In pediatric patients, the most common inflammatory pathology was antrochoanal polyps, followed by allergic fungal sinusitis. On the other hand, chronic sinusitis without nasal polyps is the most common in adults, followed by antrochoanal polyps. The mean duration of clinical manifestations before diagnosis in pediatric patients was significantly shorter than that in adults (P=0.001). The most common symptoms in both pediatric and adult patients were anterior nasal discharge and nasal obstruction. Proptosis was significantly higher in pediatric group than in adult group (P=0.015). On computed tomography (CT), the most commonly affected sinus in both pediatric and adult patients was the maxillary sinus followed by the anterior ethmoid sinus. Bone expansion, erosion and involvement of adjacent structures were significantly higher in pediatric patients (P=0.028, 0.027 respectively). Conclusion: Pediatric patients have a high incidence of antrochoanal polyps and allergic fungal sinusitis as unilateral inflammatory lesions. These lesions require surgical management. Inflammatory paranasal sinus lesions in pediatric patients have a shorter duration of clinical manifestations and a higher incidence of bone erosion and involvement of adjacent structures; therefore, early diagnosis and management prevent complications. [ABSTRACT FROM AUTHOR]

Purpose of the Review: Fungal sensitizations have been associated with hypersensitivity reactions with variable levels of evidence available to link types of fungi with human disease. We conducted systematic reviews of the literature to identify the strength of evidence linking lesser-studied fungi for which there are commercially available extracts to identify populations in which they were useful in clinical practice. Recent Findings: Excluding five fungi for which hundreds of articles were identified, there are 54 articles on the remaining fungi with clinical data. For 12 of the fungi, the prevalence of fungal sensitization varies in different hypersensitivity disorders due to factors related to geographic areas, age, and other underlying medical conditions. There were no studies linking seven genera to human disease. Summary: Most of the commercially available fungal extracts are uncommonly associated with hypersensitivity reactions in humans. Specific extracts may be useful in particular disease states such as allergic fungal sinusitis or allergic bronchopulmonary mycosis, or when routine testing fails to identify a cause of uncontrolled disease, such as in asthma. [ABSTRACT FROM AUTHOR]

Chronic rhinosinusitis with nasal polyposis is a common inflammatory condition, with subtypes like aspirin-exacerbated respiratory disease, allergic fungal rhinosinusitis, and central compartment atopic disease sharing a common type 2 inflammatory pathway. Respiratory biologic therapies have been developed that target type 2 inflammation. In this article, we discuss the use of respiratory biologic therapies for nasal polyposis in general, as well as within the various subtypes of nasal polyps. Further, we discuss future roles of novel biologic therapies targeting type 2 inflammation in nasal polyposis. [ABSTRACT FROM AUTHOR]

This article discusses the secondary repair of iatrogenic cerebrospinal fluid (CSF) leaks during functional endoscopic sinus surgery (FESS) in a tertiary-care center. The study included 12 patients who underwent secondary repair of CSF leaks. The average time from initial surgery to presentation at the institution was 8.25 days, and CSF leaks were recognized intraoperatively in 33.3% of cases. The management included updated CT scans, intravenous ceftriaxone, and operative repair tailored to each patient. Acetazolamide was started postoperatively for patients with a BMI greater than 40, and there were no cases of persistent CSF leaks or meningitis. [Extracted from the article]

A non-invasive type of chronic sinusitis named allergic fungal rhinosinusitis (AFRS), which is a variant of allergic bronchopulmonary aspergillosis with nasal obstruction, was first described in 1976. The goal of this article was to provide an overview of various treatment approaches and how they can be used to control AFRS. Since this is an inflammatory disease rather than an invasive fungal infection, the treatment tries to modulate inflammation and reduce disease burden. A comprehensive treatment strategy must incorporate medicinal, surgical, biological, and immunological techniques. Owing to the chronic nature of allergic fungal rhinosinusitis and its high propensity for flare-ups and recurrence, multiple procedures are frequently required. The most likely method of establishing a long-term disease control for AFRS is a comprehensive management strategy that integrates medical, surgical, and immunological care. However, there are still disagreements regarding the exact combinations. In this review, we have mentioned different modalities in the management of AFRS, such as monoclonal antibodies, probiotic Manuka honey, and aPDT among others, some of which are promising but require further research. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to analyze barriers to medical care and follow‐up in patients with allergic fungal rhinosinusitis (AFRS). Study Design: Cross‐sectional questionnaire‐based study with retrospective chart review. Setting: Tertiary Medical Center. Methods: Subjects with AFRS and chronic rhinosinusitis with nasal polyps (CRSwNP) were prospectively recruited for completion of the Barriers to Care Questionnaire (BCQ) and formal chart review. Results: Fifty‐nine AFRS and 51 CRSwNP patients participated. AFRS patients were more likely to be lost to follow‐up within 6 months of surgery (35.6% vs 17.7%, P = 0.04) and no‐show at least 1 appointment (20.3% vs 5.9%, P = 0.03) compared to CRSwNP patients. Men with AFRS were more likely to have only a single follow‐up visit (37.0% vs 3.1%, P < 0.001) and be lost to follow‐up (66.7% vs 9.4%, P < 0.001) than women. There were no significant differences in the BCQ between groups; however, rate of questionnaire completion was lower in the AFRS group than the CRS group (62.7% vs 80.4%, P = 0.042). AFRS patients who did not complete the BCQ were more likely to be male (63.6% vs 35.1%, P = 0.034), lost to follow‐up (77.3% vs 10.8%, P < 0.0001), and have a single follow‐up visit (40.9% vs 5.4%, P < 0.0001). Younger age was associated with increased likelihood of having a single follow‐up visit (odds ratio 1.143, 95% CI 1.022‐1.276). Conclusion: Young, male AFRS patients are more frequently lost to follow‐up after surgery and less likely to complete questionnaires assessing barriers to care. Further investigation is needed to assess barriers to follow‐up in these at‐risk groups. [ABSTRACT FROM AUTHOR]

Background and Objectives: Chronic sinusitis is a commonly encountered diagnosis for otorhinolaryngologists. The profound negative effect of rhinosinusitis on patients' quality of life is frequently overlooked, and surgical lines of treatment are numerous. The aim of the study was to assess the comparative efficacy of endoscopic middle meatal antrostomy with the endoscopic prelacrimal recess approach, combined with middle meatal antrostomy in the treatment of unilateral chronic maxillary sinus lesion. Materials and Methods: Thirty patients with unilateral chronic maxillary sinus lesions enrolled in the study at Alahsa hospital. Patients were divided into two groups: 15 treated through a middle meatal antrostomy and 15 treated via a combined middle meatal antrostomy and prelacrimal recess approach. Demographic and clinical information of the patients, including the medical history, CT scan findings, diagnosis, recurrence, and complications, were gathered and analyzed. Pre- and postoperative clinical findings were graded utilizing the Lund–Kennedy Endoscopic Scoring System. Results: The enrolled patients varied in age from 18 to 56, with 60% being male and 40% being female. Antrochoanal polyp, maxillary sinus mucocele, and unilateral allergic fungal sinusitis were among the pathological diagnoses. The follow-up period averaged 14.3 months. Following surgery, two patients in Group II encountered nasal discomfort, which included synechia and epiphora. The success rate for preserving a patient's disease-free condition was 86.7%. A statistically significant difference in disease-free incidence was observed among the patients in group II. In group I, recurrence was identified in 26.7% of the patients. The postoperative symptoms diminished considerably, and the VAS score was reduced substantially. In Group II patients, however, there was no significant difference in scarring. Clinically significant differences were observed in the mean total Lund–Kennedy Endoscopic scores when compared to their preoperative values. Conclusions: Achieving endoscopic access to the sinus's anterior, lateral, inferior, and inferomedial regions is facilitated by operating via the prelacrimal recess, which is the most advantageous approach. This approach facilitates rapid mucosal healing by maintaining the integrity of the nasolacrimal duct and mucosal covering. The specific pathology, surgical objectives, surgeon expertise, and equipment accessibility influence the choice of endoscopic surgical technique. [ABSTRACT FROM AUTHOR]

Background: Central compartment atopic disease (CCAD) is an emerging phenotype of chronic rhinosinusitis with nasal polyposis (CRSwNP) characterized by prominent central nasal inflammatory changes. This study compares the inflammatory characteristics of CCAD relative to other phenotypes of CRSwNP. Methods: A cross‐sectional analysis of data from a prospective clinical study was performed on patients with CRSwNP who were undergoing endoscopic sinus surgery (ESS). Patients with CCAD, aspirin‐exacerbated respiratory disease (AERD), allergic fungal rhinosinusitis (AFRS), and non‐typed CRSwNP (CRSwNP NOS) were included and mucus cytokine levels and demographic data were analyzed for each group. Chi‐squared/Mann‐Whitney U tests and partial least squares discriminant analysis (PLS‐DA) were performed for comparison and classification. Results: A total of 253 patients were analyzed (CRSwNP, n = 137; AFRS, n = 50; AERD, n = 42; CCAD, n = 24). Patients with CCAD were the least likely to have comorbid asthma (p = 0.0004). The incidence of allergic rhinitis in CCAD patients did not vary significantly compared to patients with AFRS and AERD, but was higher compared to patients with CRSwNP NOS (p = 0.04). On univariate analysis, CCAD was characterized by less inflammatory burden, with reduced levels of interleukin 6 (IL‐6), IL‐8, interferon gamma (IFN‐γ), and eotaxin relative to other groups and significantly lower type 2 cytokines (IL‐5, IL‐13) relative to both AERD and AFRS. These findings were supported by multivariate PLS‐DA, which clustered CCAD patients into a relatively homogenous low‐inflammatory cytokine profile. Conclusions: CCAD has unique endotypic features compared to other patients with CRSwNP. The lower inflammatory burden may be reflective of a less severe variant of CRSwNP. [ABSTRACT FROM AUTHOR]

This case report describes our treatment of a persistent periantral abscess in a 35-year-old woman. The abscess developed following a zygoma-reduction surgery, during which a preexisting fungal ball had not been addressed. Our comprehensive treatment approach included functional endoscopic sinus surgery, fungal ball removal, abscess drainage, and debridement. Two weeks postoperatively, the patient's symptoms had resolved. A 6-month postoperative follow-up revealed no signs of recurrence or complications, and the patient reported satisfactory functional and aesthetic results. This case underscores the importance of thorough preoperative evaluations and raises awareness about the potential risks of untreated asymptomatic pathologies, which can potentially progress and lead to further complications. [ABSTRACT FROM AUTHOR]

Background: Allergy immunotherapy (AIT) with fungal extracts is not as straight forward as that with other inhalants. The complexities relate to the number of airborne fungal spores, the limited data on the exposure to the spores of individual species of fungi and their clinical importance, the poor quality of the fungal allergen extracts that are available for the diagnosis and treatment, and the lack of controlled studies establishing dosing and efficacy of AIT with fungal extracts except for Alternaria. Objective: The objective was to review what is known with regard to the role of fungi in causing allergic respiratory diseases as well as the evidence that exists for the role of AIT as a treatment for these conditions. Methods: A search was conducted of PubMed, textbooks, known articles on immunotherapy with fungal extracts, and references derived from these primary sources. Results: Nine immunotherapy studies that used Alternaria or its major allergen Alt a 1 and two studies that used Cladosporium herbarum were identified. When a good quality extract was administered in adequate doses, immunotherapy with Alternaria was as effective as that with other inhalant allergens. There was a suggestion of efficacy with a specially prepared Cladosporium extract, but systemic reactions were common and limited the tolerated dose. The use of immunotherapy as an adjunct treatment for allergic fungal sinusitis is briefly reviewed, but controlled trials are lacking. Conclusion: Fungal immunotherapy should largely be limited to Alternaria alternata and perhaps C. herbarum. Under conditions of demonstrated exposure to a particular species of fungus and with symptoms that correlate with that exposure as well as availability of an apparently potent extract of that fungus to which the patient is sensitive that fungus may be considered for immunotherapy. Fungal (mold) mixes should not be used for diagnosis or therapy. [ABSTRACT FROM AUTHOR]

Objective: We investigated the anatomical and dental factors associated with unilateral maxillary sinus fungal ball (MSFB). Also, we evaluated the effect of combinations of those factors on the incidence of MSFB. Methods: Three hundred patients were divided into MSFB, normal, and chronic rhinosinusitis (CRS) groups. We reviewed paranasal computed tomography scans for the presence of deviated nasal septum, concha bullosa (CB), Haller cells, and various dental factors. Also, we measured the ethmoid infundibulum, maxillary natural ostium, and CB. Results: Maxillary sinus fungal ball showed a more significant association with CB compared to the other 2 groups (37%, P <.05). The MSFB group had a lower rate of Haller cells than the normal group (10% vs 22%, respectively; P <.05). Also, the MSFB group had a wider maxillary sinus ostium than the normal group (7.07 ± 1.8 vs 5.48 ± 1.3 mm; P <.01). Moreover, the combination of CB and Haller cells was significantly associated with a decreased rate of the fungal ball (P =.047, odds ratio = 0.694). The dental factors were more prevalent in the MSFB and CRS groups (73% and 75%, respectively) than in the normal group (32%, P <.001). Conclusions: Maxillary sinus fungal ball is significantly associated with CB, Haller cells, an increased maxillary sinus ostium size, and dental factors. [ABSTRACT FROM AUTHOR]

Allergic fungal rhinosinusitis (AFRS) and eosinophilic mucin chronic rhinosinusitis (EMRS) are two forms of chronic sinusitis distinguished by the presence (AFRS) or absence (EMRS) of fungal elements in sinus mucin. Detection of the fungal elements, however, is complex and it is difficult to say whether EMRS is in fact an entity distinct from AFRS. The aim of the present study, based on a retrospective series of AFRS and EMRS, was to identify the specific clinical and radiological elements distinguishing between the two. A 2-center retrospective observational study following STROBE guidelines included patients managed for AFRS or EMRS between 2009 and 2022. Clinical, mycological, pathologic and radiological data were collected. Type of treatment and disease progression were also analyzed. Intergroup comparison used Student's test for mean values of quantitative variables, with calculation of P -values, and Pearson's Chi2 test or Fisher's exact test for categoric variables, with calculation of relative risk and 95% confidence intervals. The AFRS group comprised 41 patients and the EMRS group 34. Demographic data were comparable between groups. EMRS showed a higher rate of asthma (79.4 vs. 31.4%; P < 0.001), more severe nasal symptomatology (rhinorrhea, P = 0.01; nasal obstruction, P = 0.001), and more frequent bilateral involvement (85.3 vs. 58.5%; P = 0.021). AFRS showed more frequent complications (19 vs. 0%; P = 0.006). Radiologically, mucin accumulation was greater in AFRS, filling the sinus in 84.2% of cases, versus 26.3% (P < 0.001), with more frequent sinus wall erosion (19 vs. 5.8%; P = 0.073). The recurrence rate was higher in EMRS: 38.2 vs.21.9% (P = 0.087). The present retrospective study found a difference in clinical and radiological presentation between AFRS and EMRS, with EMRS more resembling the presentation of severe nasal polyposis. [ABSTRACT FROM AUTHOR]

Background: A non-invasive sinusitis that often affects young persons is allergic fungal sinusitis. Objective: This study aimed to explain the potential risk factors that may affect patients suffering from nasal polyps with allergic fungal sinusitis (AFS)local anatomical variants or general illnesses. Patients and methods: This case-controlstudy was carried out on 160 patients (80 patients with allergic nasal polyposis with fungal sinusitis and 80 cases with nasal polyp without superimposed fungal infection). The study was performed at the ENT Department, Faculty of Medicine, Al-Azhar University, Assuit, from 21st May 2018 to 21st May 2022. Results: The mean vitamin D level was considerably lower in the case group (27.86 ±5.92 ng/mL) than in the control group (38.98 ±5.92 ng/mL). The cases had significantly higher anatomical abnormalities (deviated nasal septum and inferior turbinate hypertrophy) than the control group (P value <0.001). MW-I was lower significantly in the case group than in the control group while ML-I was significantly longer in the case group than in the control group (P value <0.001). Deviated nasal septum, vitamin D, MW-I, and ML-I were significant independent predictors for fungal sinusitis (P value< 0.001) Conclusions: Features of anatomical abnormalities, such as a notably deviated septum, MW-I, and ML-I may increase the incidence of fungal sinusitis more than general illness as bronchial asthma and DM. Vitamin D deficiency may have a role in developing superimposed fungal sinusitis. [ABSTRACT FROM AUTHOR]

Allergic fungal rhinosinusitis (AFRS) and allergic bronchopulmonary mycosis (ABPM) are inflammatory disorders of the respiratory tract resulting from type 1 and 3 hypersensitivity reactions against fungi. The hallmark features of both diseases are eosinophil infiltration into the airway mucosa caused by localized type 2 inflammation and concomitant viscid secretions in the airways. Eosinophilic mucin-induced compression of adjacent anatomic structures leads to bone erosion and central bronchiectasis in the upper and lower respiratory tracts, respectively. Although these diseases share common features in their pathogenesis, they also exhibit notable differences. Epidemiologic findings are diverse, with AFRS typically presenting at a younger age, exhibiting less complicated bronchial asthma, and displaying lower total immunoglobulin E levels in laboratory findings compared with ABPM. Furthermore, despite their similar pathogenesis, the rarity of sinio-bronchial allergic mycosis in both AFRS and ABPM underscores the distinctions between these two diseases. This review aims to clarify the similarities and differences in the pathogenesis of AFRS and ABPM to determine what can be learned about AFRS from ABPM, where more is known. [ABSTRACT FROM AUTHOR]

Effect of absorbable nasal packing saturated with ciprofloxacin and dexamethasone following endoscopic sinus surgery: A prospective cohort study Keywords: chronic rhinosinusitis; endoscopic sinus surgery; nasal packing; outcomes EN chronic rhinosinusitis endoscopic sinus surgery nasal packing outcomes 1801 1804 4 08/25/23 20230901 NES 230901 INTRODUCTION Enhancing wound healing in the immediate postoperative setting may reduce complications and improve outcomes after endoscopic sinus surgery (ESS).[[1], [3]] A certain combination of sinus rinses, nasal packing, antibiotics, or steroids is frequently prescribed. In this study we assess the effect of chitosan-based absorbable nasal packing saturated with ciprofloxacin and dexamethasone on postoperative wound healing using endoscopic Lund-Kennedy (LK) scores. [Extracted from the article]

Allergic fungal rhinosinusitis (AFRS) is primary, Th2-mediated, chronic rhinosinusitis, which is diagnosed when the criteria defined by Bent and Khun are met. The disease is most common in countries located in the subtropical and tropical regions characterized by high temperatures and high levels of humidity, which favour the wider occurrence of fungi in the environment. The presence of specific IgE antibodies directed against fungal allergens, which is one of the diagnostic criteria, proves the systemic nature of the disease and allows one to distinguish AFRS from eosinophilic fungal rhinosinusitis. There is no unified treatment method for AFRS described in the literature, and relapses are common. Sinus surgery remains the treatment of choice. Oral and topical steroid therapy plays an important role in the treatment process. The effectiveness of antifungal treatment and immunotherapy is unclear. Biological treatment, the results of which are promising, has raised great hopes. The aim of this study was to reveal how often AFRS occurs in European countries, what environmental factors influence its development, and how important it is to specify its diagnostic criteria and treatment methods. We present an overview of the available literature. In addition, we share our own experience and describe two cases of AFRS diagnosed and treated at our centre. [ABSTRACT FROM AUTHOR]

Abstract Background Chronic rhinosinusitis with nasal polyps (CRSwNP) is an allergic response characterized by type 2 inflammatory reactions mediated by T helper 2 cells (Th2). Th2 is characterized by elevated type 2 cytokines related to the humoral response, including Interleukin-4 (IL-4), IL-5, IL-6, IL-9, IL-10, IL-13, IL-25 and IL-33. Allergic fungal sinusitis (AFS) is a distinguishable form of CRSwNP and is characterized by primary localized disease with non-invasive fungal hyphae, which causes immunoglobulin E (IgE)-mediated mucosal hypersensitivity resulting in the formation of eosinophilic mucin. Interleukin-5 (IL-5) is a pro-inflammatory factor that plays a very important role in eosinophil biology. Objective To explore the relation between IL-5 tissue protein expression and AFS. Methods A prospective study performed on 70 patients divided into 2 groups (50 cases of AFS and 20 control who underwent septoplasty and partial inferior turbinectomy) to assess the role of IL5 in AFS compared to control. Results IL-5 was overexpressed in polyps of AFS patients compared to the control group denoting AFS as an eosinophilic mediated type 2 inflammation and highlighting a positive correlation with Lund MacKay radiological score and Sino-nasal Outcome Test (SNOT-22) score for severity of chronic rhinosinusitis (CRS) symptoms. Conclusion IL-5 plays a pivotal role in the pathogenesis and severity of AFS. Thus, our results provide encouraging evidence supporting targeting IL5 as an eligible therapy of promising benefits in AFS.

Fungal sinusitis is broadly classified into invasive and non invasive types. Invasive type presents with fungal hyphae within the mucosa, submucosa, bone, or blood vessels of the paranasal sinuses and includes Acute Invasive Fungal Sinusitis, Acute Fulminant, Chronic Invasive Fungal Sinusitis, Chronic Granulomatous Fungal Sinusitis. Invasive forms of fungal rhinosinusitis are rare and confined to groups of patients who are immunocompromised (Key in Fungal rhinosinusitis). Noninvasive type shows absence of fungal hyphae within the mucosa paranasal sinuses. It includes Allergic Fungal rhinosinusitis, Fungus Ball (fungus mycetoma). The study was performed on a total of 30 patients, in Department of Otorhinolaryngology, at our hospital after getting approved by the Instituitional Human Ethical Committee. We selected 30 patients diagnosed with allergic fungal sinusitis and studied their varied clinical presentations and treatment for a period of 1 year. It was a prospective case series type of study. Patients who presented with symptoms of allergic fungal rhinosinusitis were included. Patients who were referred with complaints of proptosis, diplopia were also included to rule out allergic fungal rhinosinusitis and its complications. Patients diagnosed with chronic granulomatous infection of nose and invasive fungal sinusitis were excluded. Evaluation of patients involved a detailed case history followed by clinical examination and radiologic investigation. After getting proper consent, we did a study of 30 patients who presented to our outpatient department with complaints of sinusitis. Our study included 12 male and 18 female patients. Among these patients, all of them had complaints of frequent allergic rhinosinusitis, nose block, facial heaviness. 12 among them had olfactory disturbances, reduced perception of smell. 4 patients presented with visual disturbances and proptosis which subsided after endoscopic sinus surgery was done.24 among these patients had presence of allergic fungal mucin in their nasal secretions and 10 patients had history of associated atopy and asthma and elevated Ig E levels. And 20 of these patients showed high eosinophil counts. All these patients in our case series were under the age group 22–70 years. These patients were treated with a course of nasal sprays and preoperative steroids in case of extensive polyposis and were taken up for functional endoscopic sinus surgery. Polypoidal mucosa was removed, diseased tissue was cleared, sinus blockage was released and fungal mucin/tissue bits were sent for histopathological analysis, KOH mount and fungal culture. This study included a series of cases which showed a wide range of the various clinical presentations that occur in cases of allergic fungal rhinosinusitis, its diagnosis and treatment. The advantage of this study was we had analyzed a good number of cases with varied presentations. Since AFRS is closely related with EMRS, CRS a proper clinical, radiological and immunological evaluation of the cases help in knowing the correct diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Keywords: aspergillosis; invasive fungal infection; sinusitis EN aspergillosis invasive fungal infection sinusitis 1024 1033 10 05/29/23 20230601 NES 230601 INTRODUCTION Although the exact frequency of fungal sinusitis is unknown, emergence of endemic mycoses is growing.[1] In immunocompromised patients, fungi can permeate mucosa, rapidly progressing to critical illness within days with estimated mortality rates of 58% to 80%.[[2]] Because of the wide spectrum of severity, management, and prognosis associated with different forms of fungal sinusitis, concerted efforts have devised a classification system. Hora et al. initially classified fungal sinusitis into invasive and noninvasive types.[4] Subsequently, noninvasive fungal sinusitis is subdivided into saprophytic fungal infection, fungus ball, and allergic fungal rhinosinusitis (AFRS). AFRS = allergic fungal rhinosinusitis; AIFS = acute invasive fungal sinusitis; AML = acute myelogenous leukemia; Bil = bilateral; CIFS = chronic invasive fungal sinusitis; CGIFS = chronic granulomatous invasive fungal sinusitis; F = female; IFS = invasive fungal sinusitis; L = left; M = male; NR = not reported; R = right. Although the transformation of noninvasive fungal sinusitis to IFS remains rare, clinicians should be made aware of this potential complication in patients with fungal ball and AFRS. [Extracted from the article]

Rupture of internal carotid artery aneurysm has high mortality rate and needs high index of suspicion for immediate management. Massive epistaxis after rupture of aneurysms in the petrous part of internal carotid artery is extremely rare. In this paper, we report the first case of delayed rupture of a petrous carotid aneurysm which developed because of chronic allergic sinusitis. [ABSTRACT FROM AUTHOR]

Orbital apex syndrome (OAS) is a rare condition that usually occurs due to damage to surrounding inner and surrounding bone tissue. Orbital apex syndrome may result from a variety of conditions that cause damage to the superior orbital fissure and to the optic canal leading to optic nerve (II) dysfunction. We recently experienced a rare case of sphenoidal Aspergillosis, which damaged the adjacent cavernous sinus structures and led to the definite symptom of bilateral OAS in a 77-year-old male. We present this rare case with a brief review of these disease's entities. [ABSTRACT FROM AUTHOR]

Background: The escalating negative impact of climate change on our environment has the potential to result in significant morbidity of rhinologic diseases. Methods: Evidence based review of examples of rhinologic diseases including allergic and nonallergic rhinitis, chronic rhinosinusitis, and allergic fungal rhinosinusitis was performed. Results: The lower socioeconomic population, including historically oppressed groups, will be disproportionately affected. Conclusions: We need a systematic approach to improve healthcare database infrastructure and funding to promote diverse scientific collaboration to address these healthcare needs. [ABSTRACT FROM AUTHOR]

Keywords: pediatric epiphora; pediatric dacryocystorhinostomy; endonasal nasolacrimal intubation; sinonasal pathology EN pediatric epiphora pediatric dacryocystorhinostomy endonasal nasolacrimal intubation sinonasal pathology 1193 1201 9 05/03/23 20230401 NES 230401 Mostafa Talaat Abd-El Hakeem, SP 1 sp Adel Abdallah, SP 1 sp Rasha Abdelmoneim, SP 1 sp Ahmed Khaleel, SP 1 sp Raafat Abdallah SP 2 sp SP 1 sp Otorhinolaryngology Department, Faculty of Medicine, Minia University, Minia, Egypt; SP 2 sp Ophthalmology Department, Faculty of Medicine, Minia University, Minia, Egypt Correspondence: Mostafa Talaat Abd-El Hakeem, Email [email protected] Introduction Congenital epiphora affects up to 20% of all newborns. The third line of invasive treatment, dacryocystorhinostomy (DCR), was performed in 2 cases that failed to resolve after silicone intubation and in 12 patients suffering from recurrent or chronic dacryocystitis (4-12 years old), Figure 3. In our study, the silicone intubation stent was maintained in situ for 3-6 months.[5],[17] The DCR procedure is reserved for intubation-resistant NLDO cases and recurrent or chronic dacryocystitis patients. The results showed that the success rate in children with non-isolated nasolacrimal obstruction was comparable to that in isolated epiphora, possibly because the sinonasal pathology was diagnosed and corrected simultaneously with epiphora.[14] Endoscopic-guided NLD probing is a safe and feasible option as a primary management strategy for epiphora. [Extracted from the article]

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. [ABSTRACT FROM AUTHOR]

In this paper, we aim to study the different clinical presentations of pediatric allergic fungal sinusitis (AFS) in the Eastern Province of Saudi Arabia, and to review the experience in the diagnosis & management of AFS in children at King Fahad Specialist Hospital. This study is a retrospective case series of pediatric patients diagnosed and managed as AFS at a tertiary referral hospital in Saudi Arabia. The clinical presentation of pediatric AFS varies widely and includes unilateral, unilateral with proptosis, bilateral, alternating, isolated sphenoid and extensive with intracranial & intraorbital involvements. Children with AFS present with different clinical features when compared to adults. Therefore, they require a high index of suspicion for evaluation and early aggressive treatment. [ABSTRACT FROM AUTHOR]

Biological particles, along with inorganic gaseous and particulate pollutants, constitute an ever-present component of the atmosphere and surfaces. Among these particles are fungal species colonizing almost all ecosystems, including the human body. Although inoffensive to most people, fungi can be responsible for several health problems, such as allergic fungal diseases and fungal infections. Worldwide fungal disease incidence is increasing, with new emerging fungal diseases appearing yearly. Reasons for this increase are the expansion of life expectancy, the number of immunocompromised patients (immunosuppressive treatments for transplantation, autoimmune diseases, and immunodeficiency diseases), the number of uncontrolled underlying conditions (e.g., diabetes mellitus), and the misusage of medication (e.g., corticosteroids and broad-spectrum antibiotics). Managing fungal diseases is challenging; only four classes of antifungal drugs are available, resistance to these drugs is increasing, and no vaccines have been approved. The present work reviews the implications of fungal particles in human health from allergic diseases (i.e., allergic bronchopulmonary aspergillosis, severe asthma with fungal sensitization, thunderstorm asthma, allergic fungal rhinosinusitis, and occupational lung diseases) to infections (i.e., superficial, subcutaneous, and systemic infections). Topics such as the etiological agent, risk factors, clinical manifestations, diagnosis, and treatment will be revised to improve the knowledge of this growing health concern. [ABSTRACT FROM AUTHOR]

We conducted this study to determine if serum galactomannan (GM) can be used as a marker to implicate the invasiveness of allergic fungal rhinosinusitis (AFRS), and correlate this value with the aggressiveness of disease documented via computed tomography (CT). All paranasal CT scans done for AFRS patients prospectively over a five-year period (2015–2019) were included. An indigenous 20-point score was used to document the extent of bone erosion seen on CT, wherein a higher score meant a greater extent of bone erosion. It was then correlated with serum GM scores. The median CT scores of galactomannan-positive (GM+) patients were compared with the median CT scores of galactomannan-negative (GM−) patients 3 using Mann–Whitney U test. The patients were divided into five groups based on the extent of disease-No bone erosion, erosion of only sinus wall/orbit, 3 erosion of orbit and skull base, erosion of only skull base and lateral extension of disease into infratemporal fossa (ITF). Subgroup analysis was conducted over mean GM values in these groups using ANOVA test. p-value < 0.05 was considered significant. Statistical analysis was performed using SPSS version 25.0. A total of 92 patients were included (56 males, 36 females). No statistically significant difference was found (p-value = 0.42) between the CT scores of galactomannan-positive (GM+) group and galactomannan-negative (GM−) group. The mean GM scores amongst the five sub-groups did not show a statistically significant difference. Serum galactomannan values correlate poorly with aggressiveness of disease quantified on non-contrast CT of paranasal sinuses. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to compare the efficacy of itraconazole and systemic steroids as an adjuvant to topical steroids in post‐operative patients with allergic fungal rhinosinusitis (AFRS) using both subjective and objective outcome measurements. Design: A prospective comparative study. Setting: A tertiary care centre. Participants: Sixty patients diagnosed with AFRS were included. Patients with chronic systemic illness and those undergoing revision surgery were excluded. Post‐operative patients were divided into two groups of 30 each which received itraconazole 400 mg OD or methylprednisolone in tapering doses over 6 weeks. Main outcome measures: The outcomes were measured at the end of 6 weeks—Kupferberg endoscopic staging, absolute eosinophilic count (AEC), serum immunoglobulin (IgE), and Sino Nasal Outcome Test‐20 scores. Results: Our study showed no statistical significance in outcomes between the two groups treated with itraconazole and methylprednisolone regarding recurrence, AEC, IgE and quality of life assessment (p < 0.01). Conclusion: Itraconazole was comparable to methylprednisolone in preventing disease recurrence in the post‐operative management of AFRS. It may be a viable alternative to replacing systemic steroids where the latter may be contraindicated. Itraconazole given at a dose of 400 mg once daily for 6 weeks was a safe dose. [ABSTRACT FROM AUTHOR]