Allergic Fungal Sinusitis in India-Treatment

Jubilee Hospital, Trivandrum.

Allergic Fungal Sinusitis (AFS )can be invasive or noninvasive.

Approximately 7-10% of chronic sinusitis cases requiring surgery are caused by AFS. As the entity is gaining recognition, reports of its incidence are increasing. A warm humid climate may enhance fungal growth and amplify disease prevalence. It is more common in diabetics and immunocompromised patients. It is very commonly seen in the southern districts of Kerala and Tamil Nadu mostly those work in agriculture.

Most common etiologic agent in AFS is Aspergillus.

AFS occurs in adolescents and young adults who often have asthma that is exacerbated by their sinusitis. There is no male or female predominance. All patients are immunocompetent and have a strong history of atopy. All have nasal polyps and chronic sinusitis; many have had multiple sinus surgeries. There is no increased aspirin sensitivity despite the association with asthma and nasal polyps. Patients typically present to the otolaryngologist with acute worsening of their chronic sinusitis with nasal obstruction, headache, proptosis, and at times intracranial erosion.

The CT and MRI findings in AFS are important for distinguishing fungal sinusitis from bacterial sinusitis and sinus neoplasms. Serpiginous areas of increased attenuation on noncontrast CT, particularly on bone windows are characteristic of AFS. These hyperdense and heterogenous densities in an opacified sinus are also referred to as the “double density” sign and most likely represent higher levels of magnesium, manganese, and iron in fungal mucin.

The current therapy for AFS involves surgical extirpation of all allergic mucin if possible with aeration of diseased sinuses. Endoscopic surgical decompression with adjunctive steroids are considered initially. Most patients will experience rapid relief of nasal congestion, drainage, headache and other associated symptoms; however, this is transitory as the polyps and associated AFS symptomatology almost always recurs.

The hallmark of this disease is multiple sinonasal surgeries (including external approaches and frontal sinus obliteration) with recurrence of symptoms. These recurrences may be treated with adjunctive steroids and office debridement. Other patients may require repeat radiographic studies and repeat operative debridement.

Systemic steroids are the mainstay of therapy in ABPA flairs and have been used successfully in recurrent cases of AFS. However, steroids have multiple side effects and their use is controversial. Since surgical drainage and ventilation is possible in the sinuses but not in the lungs, some authors reserve systemic steroids for difficult or refractory cases of AFS. Others believe that systemic low dose steroids should be used indefinitely. Topical intranasal steroid sprays and saline irrigations have minimal side effects and are used routinely in the postoperative management of AFS. However, the duration and effectiveness of steroid sprays in AFS has not been proven scientifically.

Antifungal therapy

The use of topical and systemic antifungal agents is controversial. Flucanazole and Itraconazole, has had some usefulness in treatment of AFS and may be of adjunctive use in management of AFS associated with Aspergillus.