Jubilee Hospital, Trivandrum.
Allergic fungal sinusitis (AFS) now is believed to be an allergic reaction to fungi and most patients with allergic fungal sinusitis have a history of allergic rhinitis.
The common causative fungi in allergic fungal sinusitis are by Aspergillus.
Symptoms
Symptoms of nasal airway obstruction, allergic rhinitis, or chronic sinusitis that includes nasal congestion, purulent rhinorrhea, postnasal drainage, or headaches are common. Pain is uncommon among patients with allergic fungal sinusitis and suggests the concomitant presence of a bacterial rhinosinusitis.
Patients with allergic fungal sinusitis are atopic, but generally their symptoms have been unresponsive to antihistamines, corticosteroids, antibiotics and prior immunotherapy. Use of systemic corticosteroids may produce some relief of symptoms, but relapse is typical following completion of therapy. In contrast to patients who have invasive fungal sinusitis, patients with allergic fungal sinusitis always are immunocompetent.
The range of physical findings on examination is typically of nasal airway obstruction resulting from intranasal inflammation and polyposis, facial dysmorphism, consisting of proptosis. Proptosis usually occurs over long period of time hence no diplopia or visual loss is seen. Visual loss from allergic fungal sinusitis caused by compression of the ophthalmic nerve,
Diagnosis
Flexible or Rigid Endoscopy
CT/MRI imaging
Accumulation of allergic fungal mucin eventually leads to the increasingly well-recognized radiographic findings characteristic of allergic fungal sinusitis. Heterogeneous areas of signal intensity within Para nasal sinuses filled with allergic fungal mucin are frequently seen.
Treatment
Medical treatment of the disease has made use of various combinations of antifungal medications, corticosteroids, antihistamines and immunotherapy.
This comprehensive approach to management depends on complete removal of all fungal mucin usually requiring radical surgery and long-term prevention of recurrence through both corticosteroids and antifungal therapy
Systemic antifungal therapy often was used in an attempt to provide some degree of control over recurrence of allergic fungal sinusitis e.g. ketoconazole, itraconazole, and fluconazole. Topical application of antifungal agents may hold some benefit in the control of postoperative recurrence.
Itraconazole and fluconazole offer a slightly safer form of antifungal therapy but still may give rise to drug-induced cardiac dysrhythmias, hepatic dysfunction, urticaria, and agranulocytosis.
Surgical Therapy
FESS
Caldwell Luc
Lateral Rhinotomy
These surgical goals can be accomplished through a number of approaches and techniques, the choice of which ultimately is influenced by the experience and training of the surgeon. Endoscopic powered instrumentation has demonstrated its effectiveness; this technique allows for removal of soft tissue and thin bone while maintaining superb visibility. Exercise great care when using powered instrumentation because the well-recognized bone dissolution associated with allergic fungal sinusitis (AFS) increases the potential risk of inadvertent orbital and/or intracranial penetration.
Postoperative care begins immediately following surgery with nasal saline irrigation. Weekly clinic visits for about a month initially are required to allow regular inspection of the operative site and debridement of crusts and retained fungal debris.
Systemic corticosteroids, which were initiated before surgery, are continued during the postoperative period and slowly tapered during the process of healing. The length of corticosteroid treatment and the form of postoperative adjunctive medical management used to further control the disease are at the discretion of the managing physician. I treat the patients with 3-4 weeks of steroids postoperatively, starting with a similar dose of steroids received preoperatively for 10-14 days. The steroids then are tapered over the next 10-14 days.
Recurrence is not uncommon once the disease is removed. Anti-inflammatory medical therapy and immunotherapy are being employed to help prevent recurrence.
