Allergic fungal rhinosinusitis: current theories and management strategies

Human cathelicidin antimicrobial peptide is up-regulated in the eosinophilic mucus subgroup of chronic rhinosinusitis patients

BACKGROUND

Eosinophilic mucus chronic rhinosinusitis (EMCRS) patients are a subgroup of CRS with a poorer prognosis due to frequent recurrences of disease. The cathelicidin antimicrobial peptide (CAMP) is an important innate defense peptide but its role in CRS is not well characterized. The purpose of this study was to investigate CAMP mRNA and protein expression from EMCRS, CRS, and normal control patients.

METHODS

Biopsy specimens of nasal mucosa and nasal polyps were taken from 59 CRS patients and 9 controls. CAMP mRNA and protein levels were analyzed by real-time quantitative reverse-transcriptase polymerase chain reaction, immunoassay, Western blot, and immunohistochemistry.

RESULTS

The expression of CAMP mRNA was significantly increased in EMCRS patients compared with CRS patients (p = 0.0004). By immunohistochemistry, expression of CAMP was localized to nasal epithelial, submucosal glands, and inflammatory subepithelial cells. Western blotting confirmed the presence of CAMP in EMCRS, CRS, and control patients. However, we did not detect statistically significant differences in the protein levels in tissue homogenates between EMCRS, CRS, and control patients.

CONCLUSION

This study shows expression of CAMP in nasal mucosa supporting its role in innate defenses against inhaled pathogens. Although CAMP mRNA was up-regulated in EMCRS patients, there were no statistically significant differences in protein levels in the nasal mucosa of EMCRS compared with CRS patients and controls.

Usefulness of Fungiflora Y to detect fungus in a frozen section of allergic mucin

Allergic fungal sinusitis is a non-invasive disease characterized by pansinusitis with nasal polyps, with most causative agents being members of the dematiaceous fungi. Reported herein is the ninth Japanese case of allergic fungal sinusitis; an Alternaria species was culturally identified as the etiological agent. The present patient, a 32-year-old man, presented with multiple sinusitis and nasal polyps. Allergic mucin, which is a histological hallmark of this disease, was examined intraoperatively on frozen section. Although characteristic histology, including laminated masses of mucin and aggregates of eosinophils, was seen in HE-stained sections, fungal hyphae were scarce and recognized merely as clear spaces. Because fluorescent stilbene derivatives seem useful for the rapid detection of fungi, Fungiflora Y, a commercially available staining kit that includes a fluorescent stilbene derivative, was applied to the sections, and hyphae were successfully visualized using a fluorescence microscope. This stain takes only several minutes to perform. It is concluded that Fungiflora Y should be used when fungal elements are hard to find on HE stain, especially in cases in which rapid detection of fungus is requested.

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.

Rhinosinusitis: Developing guidance for clinical trials

The Rhinosinusitis Initiative was developed by 5 national societies. The current guidance document is an expansion of the 2004 publication, "Rhinosinusitis: Establishing definitions for clinical research and patient care" and provides templates for clinical trials in antimicrobial, anti-inflammatory, and symptom-relieving therapies for the following: (1) acute presumed bacterial rhinosinusitis, (2) chronic rhinosinusitis (CRS) without nasal polyps, (3) CRS with nasal polyps, and (4) classic allergic fungal rhinosinusitis. In addition to the templates for clinical trials and proposed study designs, the Rhinosinusitis Initiative has developed 6 appendices, which address (1) health outcomes, (2) nasal endoscopy and staging of CRS, (3) radiologic imaging, (4) microbiology, (5) laboratory measures, and (6) biostatistical methods.

Rhinosinusitis: developing guidance for clinical trials

The Rhinosinusitis Initiative was developed by 5 national societies. The current guidance document is an expansion of the 2004 publication "Rhinosinusitis: Establishing definitions for clinical research and patient care" and provides templates for clinical trials in antimicrobial, anti-inflammatory, and symptom-relieving therapies for the following: (1) acute presumed bacterial rhinosinusitis, (2) chronic rhinosinusitis (CRS) without nasal polyps, (3) CRS with nasal polyps, and (4) classic allergic fungal rhinosinusitis. In addition to the templates for clinical trials and proposed study designs, the Rhinosinusitis Initiative has developed 6 appendices, which address (1) health outcomes, (2) nasal endoscopy and staging of CRS, (3) radiologic imaging, (4) microbiology, (5) laboratory measures, and (6) biostatistical methods.

Health effects of mold in children

Mold is ubiquitous, and exposure to mold and its products of metabolism is unavoidable, whether indoors or outdoors. Mold can produce a variety of adverse health outcomes by four scientifically validated pathophysiologic mechanisms: hypersensitivity, toxicity, infection, and irritation. Some adverse health outcomes have been attributed to mold for which mechanisms of injury are not well defined or are implausible. This article discusses these adverse health outcomes, focusing predominantly on those for which valid associations have been established.

The role of fungi in the airway of chronic rhinosinusitis patients

PURPOSE OF REVIEW

To analyze the role of fungi in the upper and lower airway in chronic rhinosinusitis patients.

RECENT FINDINGS

Recently, the involvement of the lower airway (as asthma, small airway disease and bronchial hyperresponsiveness) in chronic rhinosinusitis patients had been documented. Fungal spores after inhalation are submerged in the aqueous lining layers of the airway. The site depends on the size of the inhaled spores. The process of inhalation, retention and clearance of fungal spores may explain the positive culture results in both normal subjects and in most chronic rhinosinusitis patients. Fungal culture of different parts of the upper and lower airway in chronic rhinosinusitis patients had no correlation with cellular changes (local eosinophilia) and other clinical parameters. In chronic rhinosinusitis, with persistence of the chronic inflammatory process, the cells may be activated nonspecifically.

SUMMARY

The role played by fungi in most chronic rhinosinusitis patients as the target antigen of initiation of such chronic inflammation is still debated. With the presence of chronic eosinophilic inflammation in chronic rhinosinusitis, an exaggerated reaction to various inhaled antigens is anticipated. The role of fungi will be confirmed only when T cells within the sinuses are shown to be actively responding to fungal antigens cultured from the sinus and with the demonstration that their elimination will stop the disease.

Systemic corticosteroids for allergic fungal rhinosinusitis and chronic rhinosinusitis with nasal polyposis: a comparative study

OBJECTIVES

To compare the effect of preoperative high-dose systemic corticosteroids on the radiographic and endoscopic appearance of allergic fungal rhinosinusitis (AFRS) and chronic rhinosinusitis with nasal polyposis (CRSwNP).

STUDY DESIGN AND SETTING

Eight AFRS and 10 CRSwNP patients underwent computed tomographic (CT) scans and then received preoperative 1 mg/kg prednisone for 10 days. CT scans were repeated 1 day before surgery and compared with pretreatment scans (Lund-MacKay radiologic scoring system). The endoscopic appearance was recorded intraoperatively.

RESULTS

The score dropped from 16 (66.4%) to 4.75 in the AFRS group and from 18.4 (23%) to 14.1 in the CRSwNP group (P=0.0064). Intraoperatively, most sinus mucosal surfaces appeared normal in the AFRS patients but were markedly edematous in the CRSwNP patients.

CONCLUSION

Radiographic response of AFRS to systemic corticosteroids is significantly greater compared with CRSwNP. This finding is supported by endoscopic observation.

Allergic fungal rhinosinusitis: diagnosis and management

PURPOSE OF REVIEW

The proper diagnosis and treatment of allergic fungal rhinosinusitis remain controversial. We discuss recent additions to the literature regarding diagnosis and treatment of this condition.

RECENT FINDINGS

There is considerable overlap in the clinical features of allergic fungal rhinosinusitis and other forms of eosinophilic mucin chronic rhinosinusitis. Type 1 hypersensitivity and characteristic computed tomographic findings may have predictive value for a final diagnosis of allergic fungal rhinosinusitis, patients with which are more likely to have bony erosion than patients with other forms of chronic rhinosinusitis. The decreases in orbital volume associated with expansive allergic fungal rhinosinusitis disease may spontaneously improve after successful treatment. Most patients have detectable fungal-specific IgE in their so-called allergic mucin. Elevated levels of fungal-specific IgG3 are a consistent finding in patients with allergic fungal rhinosinusitis and eosinophilic mucin chronic rhinosinusitis. Antifungal treatment is still considered a treatment option, but further study is needed.

SUMMARY

Type 1 hypersensitivity to fungal antigens helps to distinguish allergic fungal rhinosinusitis from other forms of eosinophilic mucin chronic rhinosinusitis. Bony erosion and orbital expansion giving rise to proptosis are prominent features of allergic fungal rhinosinusitis. Advances in medical treatment will require prospective and controlled trials.

Leczenie grzybic górnych dróg oddechowych i ucha

Fungi, in comparison with other pathogenic factors, have high pathogenicity. The number of fungal species which are able to infect people is over 500. The upper respiratory tract and ear have permanent contact with external environment which makes their ontocenoses open to continuous exchange of microorganisms of which they consist. In etiology of inflammatory processes 21 species which belonging to 3 genera (Zygomycota, Ascomycota, Basidiomycota) of fungi play important role. Administration of antifungal drugs can be: prophylactic, empiric preemptive and therapeutic. Physicians may prescribe antibiotics (mainly pollens: amphotericin B, natamycin and nystatin) and chemiotherapeutics (mainly azoles and fluorpirymidins, pigments, chlorhexidine and chlorquinaldol). In ENT practice topical and systemic drugs can be administrated. Topical lozenges include amphotericin B, clotrimazole, chlorhexidine or chlorquinaldol and oral gels: nystatin and miconazole. Some of drugs are in the form of suspension/solution, which can be used for inhalation, into the sinus, for swabbing or for lavage: amphotericin B, natamycin, nystatin, clotrimazol, flucytosine, miconazole, fluconazole, vorykonazole, caspofungin. It should be underlined that only a few of dugs can be absorbed from the digestive tract: flucytosine, fluconazole, itraconazole, ketoconazole, miconazole, vorykonazole.

Spectrum of noninfectious health effects from molds

Molds are multicellular fungi that are ubiquitous in outdoor and indoor environments. For humans, they are both beneficial (for the production of antimicrobial agents, chemotherapeutic agents, and vitamins) and detrimental. Exposure to mold can occur through inhalation, ingestion, and touching moldy surfaces. Adverse health effects may occur through allergic, infectious, irritant, or toxic processes. The cause-and-effect relationship between mold exposure and allergic and infectious illnesses is well known. Exposures to toxins via the gastrointestinal tract also are well described. However, the cause-and-effect relationship between inhalational exposure to mold toxins and other untoward health effects (eg, acute idiopathic pulmonary hemorrhage in infants and other illnesses and health complaints) is controversial and requires additional investigation. In this report we examine evidence of fungal-related illnesses and the unique aspects of mold exposure to children. Mold-remediation procedures are also discussed.

Differential diagnosis of eosinophilic chronic rhinosinusitis

Eosinophilic chronic rhinosinusitis (ECRS) encompasses a wide variety of etiologies. To date, a unifying pathophysiologic mechanism remains elusive. Eosinophilia is frequently, but not exclusively, caused by immunoglobulin (Ig)E-mediated hypersensitivity and is dominated by the associated cytokine milieu of Th2 inflammation. The provisional subcategories of ECRS include superantigen-induced eosinophilic chronic rhinosinusitis, allergic fungal sinusitis, nonallergic fungal eosinophilic chronic rhinosinusitis, and aspirin-exacerbated eosinophilic chronic rhinosinusitis. Within each subcategory, recent findings supporting distinct mechanisms that promote eosinophilic infiltration are presented, and, therefore, targeted therapeutic interventions with specific antibacterial, antifungal, or immune modulation may be indicated.

Eosinophilic mucus chronic rhinosinusitis: clinical subgroups or a homogeneous pathogenic entity?

BACKGROUND

Eosinophilic mucus chronic rhinosinusitis (EMCRS) can be subclassified using the criteria of detection of fungi in eosinophilic mucus and systemic fungal allergy. Allergic fungal sinusitis (AFS), a subgroup of EMCRS characterized by the presence of fungal allergy, is proposed to be an immunoglobulin (Ig)E-driven disease, distinct from other EMCRS subgroups. However, our recent studies cast doubt on the central pathogenic role of allergy in AFS. The purpose of this study was to examine the clinical features of EMCRS patients from the different subcategories to determine the relevance of this classification system.

METHOD

The demographic, clinical, and immunologic characteristics of the EMCRS subgroups were examined prospectively and compared with three control groups: healthy volunteers, allergic rhinitis with fungal allergy, and chronic rhinosinusitis without eosinophilic mucus.

RESULTS

EMCRS patients with allergy were younger than those without. There was no significant difference in clinicopathologic parameters between EMCRS subgroups. As a single group, EMCRS had a more severe sinus disease compared with chronic rhinosinusitis patients.

CONCLUSIONS

AFS was not clinically distinct from other subgroups of EMCRS. However, eosinophilic mucus may mark a more severe and distinct form of sinus disease.

Allergic fungal sinusitis

Many common chronic inflammatory rhinosinusitis conditions (hypertrophic sinus disease [HSD]) have the histopathological profile of allergic or asthmatic inflammation. Allergic fungal sinusitis (AFS) is both a type of noninvasive fungal rhinosinusitis and a type of HSD. AFS has clinicopathological features that make it similar, but not identical, to allergic bronchopulmonary aspergillosis (ABPA). Allergic mucin is a defined pathological entity occurring in ABPA, AFS, and in the HSD "eosinophilic mucin rhinosinusitis (EMRS)." Diagnosis of AFS requires a careful review of surgical reports, histopathology, and culture results. Treatment includes surgery and aggressive postoperative medical management of allergic inflammatory disease. Prognosis is good with integrated medical-surgical follow-up, but recurrence remains problematic. The association of ABPA, AFS, and HSD with class II genes of the major histocompatibility complex places the initiation of these inflammatory diseases within the context of antigen presentation and the acquired immune response. Pathological immunomanipulation of this response by local microbial superantigens may be a common mechanism for disease pathogenesis. Future research into the molecular biology of these related conditions may offer insight into the pathogenesis of other chronic inflammatory diseases.

Allergic fungal sinusitis

Many common chronic inflammatory rhinosinusitis conditions (hypertrophic sinus disease [HSD]) have the histopathological profile of allergic or asthmatic inflammation. Allergic fungal sinusitis (AFS) is both a type of noninvasive fungal rhinosinusitis and a type of HSD. AFS has clinicopathological features that make it similar, but not identical, to allergic bronchopulmonary aspergillosis (ABPA). Allergic mucin is a defined pathological entity occurring in ABPA, AFS, and in the HSD "eosinophilic mucin rhinosinusitis (EMRS)." Diagnosis of AFS requires a careful review of surgical reports, histopathology, and culture results. Treatment includes surgery and aggressive postoperative medical management of allergic inflammatory disease. Prognosis is good with integrated medical-surgical follow-up, but recurrence remains problematic. The association of ABPA, AFS, and HSD with class II genes of the major histocompatibility complex places the initiation of these inflammatory diseases within the context of antigen presentation and the acquired immune response. Pathological immunomanipulation of this response by local microbial superantigens may be a common mechanism for disease pathogenesis. Future research into the molecular biology of these related conditions may offer insight into the pathogenesis of other chronic inflammatory diseases.

Paranasal fungal sinusitis: contributions of histopathology to diagnosis: a report of 60 cases and literature review

Sixty cases of fungal sinusitis are presented from 2 institutions, accumulated from 1971 to 2005. Fifty cases were from a large suburban general hospital and 10 from a major university referral center. Two of the 50 and 3 of the 10, respectively, were immunocompromised patients and had acute fulminant disease. This suggests that encountering the various forms of this disease may, in part, be dependent on the referral nature of the institution. The remainder were immune competent and had chronic symptoms of nasal discharge, stuffiness, and facial pain. Imaging studies frequently showed sinus expansion, opacification, and bone erosion, although no clinical or radiographic features were predictive of extrasinus extension. Chronic fungal sinusitis is principally represented by fungus ball/mycetoma and allergic fungal sinusitis. The recent literature suggests a predominance of or a predominant interest in allergic fungal sinusitis. Hyphal colonies and the presence of allergic mucin with scattered organisms are histologic observations and are the respective keys to these diagnoses. However, the etiologic role of the fungus in chronic cases is not settled. Patients with chronic sinusitis who yield positive sinus cultures only, but have no organisms visualized histologically, are not universally regarded as having fungal sinusitis. The interest in fungal sinusitis has generated a prominent role for the pathologist. An awareness of the various forms of the disease and thorough histopathologic study, including submission of all tissues removed at surgery and recognition of allergic mucin, are essential. Acute fulminant/invasive fungal sinusitis may require frozen section for adequate management.

[Allergic fungal sinusitis and allergic broncho-pulmonary aspergillosis: a fortuitous association or a nosological rhino-bronchial entity?]

INTRODUCTION

The identification of allergic fungal sinusitis (AFS) is much more recent than that of allergic broncho-pulmonary aspergillosis (ABPA) and may still be incomplete and controversial. Their association has been only rarely reported in the literature. Is it a matter of a fortuitous association or of a well defined and/or new nosological rhino-bronchial entity?

METHODS

A retrospective study was undertaken from a series of 10 cases of AFS with 4 cases associated with ABPA and fulfilling all the diagnostic criteria described in the literature.

RESULTS

The association of AFS and ABPA may be concomitant (2 cases) or not (2 cases) with a possible time lag of several years between the onset of naso-sinal and broncho-pulmonary disease, even after recovery from the original episode. Treatment comprising steroids, endoscopic surgery (4 cases) combined with anti-fungal drugs (2 cases), led to resolution (2 cases), a considerable improvement (1 case) and therapeutic failure in 1 case (follow up longer than 4 years in all cases).

CONCLUSION

The association, concomitant or remote in time, of AFS and ABPA emphasises the unity of the upper and lower airways as well as the pathophysiological relationship between these two fungal respiratory diseases. The prevalence of this association remains low and the treatment is not standardised.

The Role of Fungi in Chronic Rhinosinusitis

Collective clinical and bench observations of the past 25 years have expanded interest in the role that fungi may play in developing and perpetuating inflammatory disease of the respiratory tract. As with any new concept, controversy regarding such a process has emerged, but it has served to stimulate increased interest and further study. Review of the current literature appears to offer strong evidence to support both allergic and nonallergic forms of noninvasive fungal inflammation. It remains to be seen whether or these forms of inflammation are inter-related or independent of one another. As investigation focusing upon these new concepts continues, it should lead to better understanding of chronic inflammatory disease of the respiratory tracts.

Aspects of oxalosis associated with aspergillosis in pathology specimens

Oxalosis (calcium oxalate deposition) is associated with various conditions, including aspergillosis. Some Aspergillus species produce oxalic acid, which reacts with blood or tissue calcium to precipitate calcium oxalate. Calcium oxalate crystals exhibit various shapes and are strongly birefringent. These occur in cytological specimens, as well as in tissues of patients with Aspergillus infection. Aspergillus species are hyaline septate moulds, and they can be accurately recognized in pathology specimens only if conidial heads (fruiting heads) are present. When these structures are not observed, detection of associated oxalosis in a mould infection supports the pathological diagnosis of aspergillosis. The presence of oxalosis is helpful when microbiological identification or immunohistological techniques for fungi are not available. Calcium oxalate crystals can induce cellular injury by several mechanisms, and there is increasing evidence that oxalosis-induced tissue damage may occasionally lead to a poor clinical outcome. This review discusses the diagnostic value and the potential clinical significance of oxalosis associated with aspergillosis.

Does the triad of fungi, bacteria and exposure to moisture have an impact on chronic hyperplastic sinusitis?

Here we evaluated a possible relationship between chronic hyperplastic sinusitis (CHS) and moisture exposure and secondly a seasonal variation of fungal and bacterial findings in the healthy nose. In 28 CHS patients sinus mucus was collected during endoscopic sinus surgery. Samples from the nasal cavities of 19 healthy volunteers were collected by nasal lavage (NAL) in January and in September. Bacterial culture and fungal staining and culture were carried out. Histological samples from the sinus mucosa were obtained. Patients' medical history and environmental factors were enquired. Mold odor or moisture problems in the home or work environment were reported by 46% of the CHS patients. Patients who reported moisture exposure did not differ significantly from those who had not been exposed with regards to microbiological findings, tissue eosinophilia, and earlier operations. Cladosporium (16%) and Alternaria (11%) were found in NAL fluid collected in the autumn from the control subjects. No fungi were isolated from samples taken during the winter. An association between CHS or fungal sinusitis and moisture damage was not apparent in the present study. The fungal findings in the nasal cavity reflect the environmental exposure. This should be taken into account when NAL is used for microbiological studies.

PRACTICAL IMPLICATIONS

Living in a moldy house or working in a similar environment may increase the risk of respiratory symptoms and infections. However, our results suggest that chronic hyperplastic sinusitis and fungal sinusitis are not associated with moisture exposure. The nose is a good collector of particles in the air. Especially samples taken by the nasal lavage method reflect the environmental exposure. This should be taken into account when this method is used for microbiological studies.

Allergic fungal sinusitis is a histopathologic diagnosis; paranasal mucocele is not

Allergic fungal sinusitis has been known to pathologists for two decades. During this time, multiple articles have stressed that the condition continues to be underdiagnosed. This is true, but it can also be overdiagnosed. This means that series of cases used for clinical studies usually are "contaminated" with cases that are misdiagnosed. Because the condition is often quite problematic to control, determination of the best treatment regimens is important. This will be dependent on clinical studies including only correctly diagnosed cases for study. This article discusses the steps toward making the correct diagnosis.

Alterations in eotaxin, monocyte chemoattractant protein-4, interleukin-5, and interleukin-13 after systemic steroid treatment for nasal polyps

OBJECTIVE

To determine alterations in Th2 chemokines eotaxin and monocyte chemoattractant protein-4 (MCP-4), and cytokines interleukin-5 (IL-5) and interleukin-13 (IL-13), in nasal polyps (NP) after steroid treatment.

STUDY DESIGN

Cytokine/chemokine levels were measured in NP before and after steroid therapy and compared to control sinus mucosa.

RESULTS

Twenty-one patients (control = 7, NP = 14) were enrolled. Eotaxin and MCP-4 were significantly higher than control tissue (P = 0.004 and 0.003). All four mediators decreased after steroid treatment (P < 0.03). IL-5 and IL-13 in untreated polyps were not significantly different from controls. Patients showed clinical improvement according to SNOT-20 scores (average presteroid score 19, poststeroid score 13) and endoscopic grading (1.75 each side presteroid, 1.13 poststeroid).

CONCLUSIONS

Steroids significantly decreased all cytokine/chemokine levels, but the impact on Th2 chemokines was of a much greater magnitude.

SIGNIFICANCE

Novel approaches to block inflammatory mediators, particularly Th2 chemokines, may lead to better control of nasal polyposis in the future.

Allergic fungal sinusitis: can we predict the recurrence?

OBJECTIVE

The goal of the present study was to find out if recurrence can be predicted in cases of allergic fungal sinusitis. We also studied the influence of postoperative corticosteroid therapy on recurrence following surgery.

STUDY DESIGN AND SETTING

This study was conducted at the ENT Department of Al Nahdha Hospital, which is a tertiary referral and teaching hospital in Muscat, Sultanate of Oman. The study is a retrospective analysis of 32 cases of allergic fungal sinusitis. Age, sex, extent of disease, and preoperative serum IgE levels were compared in patients who had recurrence with those who did not. We also studied the incidence, onset, and severity of recurrence in patients who received systemic corticosteroid as postoperative therapy and compared these values to those who received nasal corticosteroid spray only.

RESULTS

No statistically significant difference was noted in the parameters of age, sex, extent of disease, and preoperative serum IgE levels when these values were compared in the group of patients who had recurrence (8 patients) with the group of patients who did not (32 patients). No statistically significant difference was found in the incidence of recurrence in patients in whom systemic corticosteroids were used postoperatively (17 patients) compared with patients who used nasal corticosteroid spray only (15 patients). However, when the patient had a recurrence, when it occurred it was earlier and more severe in patients who used nasal corticosteroid spray only (4 patients).

CONCLUSIONS

At the present time, it is not possible to predict recurrence using parameters of age, sex, extent of disease, and serum IgE levels. Larger number of patients preferably in a prospective multicenter meta study are required to address this issue. Though use of systemic corticosteroid does not decrease the incidence of recurrence, it may delay the onset of recurrence and decrease the severity of recurrence.

Allergic fungal rhinosinusitis

The combination of nasal polyposis, crust formation, and sinus cultures yielding Aspergillus was first noted in 1976 by Safirstein, who observed the clinical similarity that this constellation of findings shared with allergic bronchopulmonary aspergillosis (ABPA). Eventually, this disease came to be known as allergic fungal rhinosinusitis (AFRS). As clinical evidence of AFRS accumulated, controversy regarding its etiology, pathogenesis, natural history, and appropriate treatment naturally emerged. Despite past and current efforts, many of these controversies remain incompletely resolved, but continuing clinical study has illuminated some aspects of the disease and has led to an improved understanding of AFRS and its treatment. In this article, we review current data and theories regarding the pathophysiology and clinical presentation of AFRS, as well as the roles of various surgical and nonsurgical forms of therapy.

Rhinologic pharmacotherapy in rhinoplasty

Rhinoplasty surgeons inevitably encounter therapeutic considerations in managing their patients, and a thorough understanding of nasal function, as well as of disorders of the nose and sinuses, is requisite for positive clinical outcomes. Patients suffering from allergic rhinitis are not precluded from undergoing rhinoplasty, whereas other disease processes may warrant an otolaryngologic evaluation before proceeding with surgery. A thorough medical history and examination elucidate sinonasal disease conditions that may not improve after septorhinoplasty but potentially could respond to pharmacologic therapy.

Overview of fungal rhinosinusitis

The incidence of fungal rhinosinusitis has increased to such extent in recent years that fungal infection should be considered in all patients with chronic rhino sinusitis. In India though the disease was reported earlier only from northern regions of this country, nowadays the disease is increasingly diagnosed from other parts as well. The disease has been categorized with possible five types: acute necrothing (fulminant), chronic invasive, chronic granulomatous invasive, fungal hall (sinus mycetoma), allergic. The first three types are tissue-invasive and the last two are non-invasive fungal rhinosinusitis. However, the categorization is still controversial and open to discussion. Chronic fungal rhinosinusitis can occur in otherwise healthy host and Aspergillus flavus is the common etiological agent in Indian scenario. The pathophys iologic mechanism of the disease remains unclear. It may represent an allergic IgE response, a cell-mediated reaction, or a combination of two. Early diagnosis may prevent multiple surgical procedures and lead to effective treatment. Histopathology and radio-imaging techniques help to distinguish different types and delineate extension of disease process. Culture helps to identify the responsible etiological agent. The presence or absence oj precipitating antibody correlates well with disease progression or recovery. The most immediate need regarding management is to establish the respective roles of surgery and antifungal therapy. Non-invasive disease requires surgical debridement and sinus ventilation only, though, additional oral or local corticosterold therapy may be beneficial in allergie type. For invasive disease, the adjuvant medical therapy is recommended to prevent recurrence and further extension. Itraconazole has been found as an effective drug in such situation. Patients with acute neerotizing type require radical surgery and amphotericin B therapy.

Categorization of eosinophilic chronic rhinosinusitis

PURPOSE OF REVIEW

The presence of eosinophilia histopathologically in sinusitis is frequently associated with greater disease objectively and a decreased likelihood of surgical success. Eosinophilic chronic rhinosinusitis encompasses a wide variety of etiologies and associations that can be grouped under this umbrella term. In addition, this term can be further divided into those patients with no polyps and those with polyps. The purpose of this review is to detail the epidemiology of eosinophilic chronic rhinosinusitis, to define known and potential subcategories, and to discuss targeted therapeutic interventions. Eosinophilia is frequently, but not exclusively, caused by IgE-mediated hypersensitivity and is dominated by the associated cytokine milieu of Th2 inflammation. Thus, allergic rhinitis or allergy is a subcategory and not synonymous with eosinophilic chronic rhinosinusitis.

RECENT FINDINGS

Recent findings supporting mechanisms that promote eosinophilic infiltration are discussed and include the following subcategories: super antigen-induced eosinophilic chronic rhinosinusitis, allergic fungal sinusitis, nonallergic fungal eosinophilic chronic rhinosinusitis, and aspirin-exacerbated eosinophilic chronic rhinosinusitis. Undoubtedly there are other mechanisms and categorizations of eosinophilic chronic rhinosinusitis as yet unknown. It is possible, and in fact probable, that some patients may have overlapping mechanisms for eosinophilia. Corticosteroid therapy is an important treatment across all eosinophilic disorders and a profoundly potent but nonspecific antiinflammatory agent. Within each subcategory a specific antibacterial, antifungal, or immune modulation may be indicated.

SUMMARY

The subcategories of eosinophilic chronic rhinosinusitis are discussed in light of recent findings and treatment recommendations.

Craniocerebral Aspergillosis of Sinonasal Origin in Immunocompetent Patients: Clinical Spectrum and Outcome in 25 Cases

OBJECTIVE:

Craniocerebral aspergillosis of sinonasal origin has been reported mainly in immunocompromised patients with high mortality, and it has been described very infrequently in immunocompetent hosts. This retrospective study focuses on clinical outcome in relation to anatomic locations of invasive aspergillosis of sinonasal origin in immunocompetent patients with emphasis on our preliminary experience with use of preoperative orally administered itraconazole.

METHODS:

Medical records of patients treated in two tertiary care hospitals from 1991 to 2003 were reviewed retrospectively. All patients had radiological evidence of disease in the paranasal sinuses with or without intracranial extension. The study cohort was divided into three types on the basis of area of involvement revealed by computed tomographic or magnetic resonance imaging scans of brain. All patients underwent surgical intervention and treatment with antifungal therapy. Preoperative orally administered itraconazole therapy was used in four patients on the basis of neuroradiological features. Clinical outcome was assessed with the Glasgow Outcome Scale, and univariate analysis of prognostic factors was performed with 95% confidence interval (P = 0.05).

RESULTS:

Mean patient age was 36.5 years (range, 14–74 yr) with a male preponderance (male-to-female ratio, 23:2). Nasal stuffiness (n = 13), headaches (n = 10), proptosis (n = 9), and nasal discharges (n = 7) were major presenting clinical features. Radiological data were obtained by computed tomographic (n = 25) and magnetic resonance imaging (n = 20) scans of the brain, and diagnoses were established by histopathological analysis (n = 20) or/and fungal cultures (n = 15). Preoperative orally administered itraconazole was given in four patients with intracerebral aspergillosis. Overall mortality was 28% and was highest in patients with Type 1 aspergillosis (66.7%). Type 3 aspergillosis and use of preoperative itraconazole remained statistically significant prognostic factors.

CONCLUSION:

Craniocerebral aspergillosis in immunocompetent hosts has three patterns of presentation that seem to correlate with clinical outcomes. Intracerebral aspergillosis (Type 1) is associated with the worst clinical outcome. Patients with orbital and cranial base aspergillosis (Type 3) had good recovery. Intracranial extradural aspergillosis (Type 2) remained intermediate on the Glasgow Outcome Scale. Preoperative orally administered itraconazole therapy may improve clinical outcome in patients with intracerebral aspergillosis. Prospective clinical studies are required to make firm clinical therapeutic recommendations.

Allergic fungal sinusitis

AFS is an increasingly recognized form of HSD, now reported throughout the world. It is probably the most frequently occurring fungal rhinosinusitis disorder. The term fungal sinusitis is no longer appropriate because the five categories of fungal rhinosinusitis can now be differentiated. Each category of fungal rhinosinusitis disorder carries different treatment approaches and prognosis. Diagnostic error can be minimized by adhering to strict diagnostic criteria. The analogy (but not identity) of AFS to ABPA has been supported by histopathology, immunopathology, and the clinical response to OCS treatment. AFS represents a true medical surgical disorder in which both surgery and postoperative medical treatment, if properly coordinated between medical and surgical specialists, leads to the best patient outcomes. Continued advances in the understanding of the immunogenetics and immunopathogenesis of AFS may provide fundamental insights into molecular mechanisms operant in other chronic inflammatory disorders, including other chronic eosinophilic-lymphocytic respiratory mucosal disorders such as common forms of HSD and chronic severe asthma.

La Sinusite Fongique Allergique (SFA)

OBJECTIVES

Diagnosis, nosological individualization, and treatment of allergic fungal sinusitis remain difficult and controversial despite the increasing number of publications. We present ten cases of allergic fungal sinusitis and review the literature to highlight the main clinical, radiological, biological, immunoallergological, mycological, and therapeutics features.

MATERIAL AND METHODS

This retrospective study included ten patients (six men and four women, mean age 45 years) with allergic fungal sinusitis diagnosed on the basis of all diagnostic criteria reported in the literature.

RESULTS

Six patients had isolated allergic fungal sinusitis which was associated with allergic bronchopulmonary aspergillosis in the four others. Treatment combined endoscopic sinus surgery and corticosteroids, which provided good results in six patients and average results in three. Treatment failure was observed in one patient.

CONCLUSION

As in the case of allergic bronchopulmonary aspergillosis, a set of clinical, radiological, histopathological, immunoallergological and mycological criteria is necessary for precise diagnosis and to avoid fungal drift. The most appropriate endoscopic sinus surgery and the best corticosteroid regimen remain to be determined.

Fungal sinusitis: histologic spectrum and correlation with culture

Fungi are important etiologic agents of sinusitis. However, features of fungal sinusitis including the histologic spectrum, diagnostic mishaps, incidence, and fungal types have not been systematically studied. From 1996 through 2001, a total of 788 surgical pathology sinus specimens from 384 cases was retrieved. Fungal sinusitis was diagnosed in 58 specimens (7%) from 47 cases (12%). Four histologic categories of fungal sinusitis were identified: (1) allergic fungal sinusitis in 34 cases (copious mucin, abundant eosinophils, Charcot-Leyden crystals (so-called allergic mucin), with rare noninvasive fungal hyphae); (2) mycetoma/fungus ball in 11 cases (tightly packed fungal hyphae without allergic mucin or tissue invasion); (3) chronic invasive fungal sinusitis in 1 case (tissue granulomas with fungal hyphae); and (4) acute fulminant fungal sinusitis in 1 case (fungal vascular invasion). The diagnosis was initially missed in 16/34 (47%) cases of allergic fungal sinusitis despite typical features; incorrect classification was noted in 47% of cases. Sixty-seven percent of cases had positive fungal cultures, dematiaceous fungi being the most common. Allergic fungal sinusitis accounted for the majority of fungal sinusitis. Although misdiagnosis or incorrect classification is rather frequent for fungal sinusitis, awareness of the distinctive morphologic features of this entity may prevent these errors.

Neurosurgical implications of allergic fungal sinusitis

OBJECT

Allergic fungal sinusitis (AFS) is a form of paranasal mycosis that often involves bone destruction and extension into the orbit and anterior skull base. Treatment consists of surgical extirpation and a course of corticosteroids. Despite frequent intracranial involvement, AFS is rarely reported in the neurosurgical literature.

METHODS

The records of 21 patients with the histological diagnosis of AFS were reviewed. The histological diagnosis was based on findings of branching septated fungi interspersed with eosinophilic mucin and Charcot-Leyden crystals without fungal invasion of soft tissue. The average age of the 21 patients in this study was 25 years (range 9-46) and the male/female ratio was 3.75:1. All patients were immunocompetent. All had a history of chronic sinusitis and imaging findings of expansile disease involving multiple sinuses. Fifteen patients had nasal polyposis, eight had erosion of bone, which was observed on computerized tomography (CT) scans, eight had disease extending intracranially, and six had disease that involved the lamina papyracea. All patients underwent transnasal and/or transmaxillary endoscopic approaches for debridement and irrigation, six underwent orbital decompression, and three underwent a bifrontal craniotomy for removal of intracranial extradural disease. No patient had a cerebrospinal fluid leak. Postoperatively, one patient was treated with amphotericin B and the other 20 were treated with a short course of corticosteroids. The follow-up period ranged from 2 to 19 years.

CONCLUSIONS

Allergic fungal sinusitis is a unique form of fungal disease that may mimic anterior skull base and paranasal sinus tumors. A cranial base team approach of neurosurgeons and otolaryngologists is recommended. Most cases can be successfully managed with transnasal and/or transmaxillary endoscopic techniques. A craniotomy is rarely indicated unless there is the suspicion of dural invasion or extensive intracranial and/or intraorbital involvement that is inaccessible from below.

Quantitative analysis of fungal DNA in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

Fungi have been recognized as important pathogens in sinusitis; however, they are equally present in patients with and without sinusitis. The authors postulated that the quantity of fungal DNA in the nose is determinant of disease, is greater in patients with chronic rhinosinusitis, and is directly correlated to their quality of life.

STUDY DESIGN

Prospective recruitment of patients with chronic rhinosinusitis.

METHODS

Objective quality of life data were collected using three validated questionnaires: the Sinonasal Outcomes Test (SNOT-20), Medical Outcomes Short-Form 36 Survey (SF-36), and Guy Marks Asthma Questionnaire (GMAQ). Endoscopically guided middle meatus mucosal samples were collected from patients with chronic rhinosinusitis and normal control subjects. Fungal-specific polymerase chain reaction was performed on each sample. Every fungal-positive sample underwent fungal-specific quantitative polymerase chain reaction analysis. Statistical analysis was used to correlate fungal DNA quantities with outcomes indices between groups.

RESULTS

Patients with chronic rhinosinusitis had a mean SNOT-20 index of 32.0 as compared with a SNOT-20 index of 17.3 (P <.01) in the normal control subjects. There were no statistical differences between the groups' indices for the SF-36 or GMAQ outcomes questionnaires. Four of 19 (21.1%) patients with chronic rhinosinusitis and 7 of 19 (36.8%) normal control subjects had positive findings for fungal DNA using polymerase chain reaction. The median relative quantity of fungal DNA to human DNA for chronic rhinosinusitis and control samples was identical (0.13) using quantitative polymerase chain reaction.

CONCLUSION

The quantity of fungal DNA in the middle meatus did not differ in patients with and without chronic rhinosinusitis and was not correlated with quality of life outcomes. Therefore, the quantity of fungi does not explain pathogenicity in patients with chronic rhinosinusitis. However, because of small sample size, the study must be replicated in a larger patient population.

Allergic fungal rhinosinusitis: a report of 8 cases

Eight patients presented with clinical manifestations such as polyps and mucin were reported to have allergic fungal rhinosinusitis (AFS). Histopathologic sections from tissue samples containing mucin from the paranasal sinuses obtained by endoscopic operation showed scattered hyphal elements within the allergic mucin but no tissue invasion. Associated fungi were 4 cases of Aspergillus flavus; a case each of Aspergillus niger and Bipolaris hawaiiensis, mixed colonization with B. hawaiiensis, and Curvularia lunata; and 1 case of Bipolaris species. Elevated immunoglobulin E level was reported in some patients ranging from (706 to 1969 IU/mL). All patients underwent endoscopic surgery; polypectomy and clearance of all affected sinuses were performed. Medical treatment involved the use of local and systemic corticosteroids. The patients have done well, with no evidence of recurrent disease.

The importance of allergy in the practice of otolaryngology

Allergy in the practice of otolaryngology is not confined to patients with typical hay fever symptoms. The otolaryngologist encounters allergy as a primary cause or secondary contributor to a number of otologic, rhinologic, and laryngologic syndromes and disorders. The practitioner of otolaryngology should be prepared to recognize these situations and to address them appropriately. Training and resources are available to help the physician wishing to achieve this capability, no matter the current level of understanding and expertise.

Intravenous antibiotics for chronic rhinosinusitis: are they effective?

PURPOSE OF REVIEW

Antibiotics have been used commonly in chronic rhinosinusitis, often because chronic rhinosinusitis has features of a prolonged bacterial sinusitis, including abnormal CT findings and positive bacterial cultures. The advent of peripherally inserted central catheters has enabled outpatient parenteral antibiotic therapy to become a convenient means of delivering potent antibiotics for various conditions when oral antibiotics may not be effective or appropriate. Chronic rhinosinusitis has been included as a condition that may benefit from outpatient parenteral antibiotic therapy; however, there are few studies that document its success and, furthermore, chronic rhinosinusitis may not always be an infectious process.

RECENT FINDINGS

Three recent uncontrolled retrospective studies examined outpatient parenteral antibiotic therapy in chronic rhinosinusitis. In one series outpatient parenteral antibiotic therapy was used as an adjunct to sinus surgery, in another it was used as an alternative to sinus surgery in the pediatric population, and in the third it was used as temporary resolution for adult patients who had failed other therapies including sinus surgery. Short-term success rates were reported in the range of 29 to 89%, but relapse rates were as high as 89%. Complication rates in theses studies ranged from 14 to 26%, including medication reactions and intravenous line problems.

SUMMARY

The role of outpatient parenteral antibiotic therapy in the treatment of chronic rhinosinusitis has not been universally established. Although outpatient parenteral antibiotic therapy may have a role in avoiding sinus surgery in select pediatric populations, the contribution to a lasting resolution in adult patients is less clear and there are possible complications. Recognizing subsets of chronic rhinosinusitis patients for whom outpatient parenteral antibiotic therapy is appropriate will be the challenge for the future.

Allergic fungal sinusitis: diagnosis and treatment

Since allergic fungal sinusitis was initially described by Millar in 1981, many have tried to define and explain the disorder. It has been labeled as the sinonasal equivalent of allergic bronchopulmonary aspergillosis; however, allergic fungal sinusitis cannot be categorized so easily. According to the literature at this time, there are five major criteria and six associated characteristics or minor criteria of patients with allergic fungal sinusitis. In reality, patients may not develop all five major criteria or have any of the associated criteria for years. Allergic fungal sinusitis is not only difficult to diagnose, but it is one of the most complicated conditions rhinologists must manage. Endoscopic sinus surgery must be used in conjunction with long-term medical therapy, oral and nasal corticosteroids, immunotherapy, antifungal therapy, and antimicrobial agents to effectively control the problem. Allergic fungal sinusitis is most likely the endpoint in a spectrum of sinonasal disease, driven by the presence of fungus and eosinophils with their inflammatory mediators. The affected nasal mucosa no longer functions properly, and a cycle of chronic edema, stasis, and bacterial superinfection results. Therapy entails disrupting the inflammatory process to allow normal mucosal function to resume.

Fungal infections of the head and neck: an update

Despite the vast literature regarding fungal infections of the head and neck, little has changed in diagnosis or management of these infections except in the nose and sinuses. Three main points regarding fungal involvement in the paranasal sinuses are evident now. First, fungi may be important in a significant percentage of patients with chronic rhinosinusitis. Second, the pathophysiologic mechanism responsible for fungal rhinosinusitis remains unclear. It may represent an allergic IgE response, a cell-mediated reaction, or a combination of the two. Finally, there is certainly a spectrum of disease thus far defined: allergic fungal sinusitis as defined by Bent and Kuhn [35], eosinophilic mucin rhinosinusitis defined by Ferguson [50], and eosinophilic fungal rhinosinusitis as proposed by Ponikau [45]. Fungal infections of the head and neck are panoramic in distribution and pathophysiology. They represent a broad range of disease of which medical science has only recently begun to uncover the surface. As research begins to unravel the complex host defense mechanisms against these pathogens from a cellular and even genetic level, the body of knowledge will continue to increase exponentially and the ability to treat patients suffering from fungal infections will improve.

Allergic fungal sinusitis associated with Trichoderma longibrachiatum

We describe allergic fungal sinusitis caused by Trichoderma longibrachiatum in a patient with a history of atopy and asthma. A Gram stain of a sinus biopsy specimen was initially thought to contain yeast cells, but when Trichoderma was recovered in culture, these cells were subsequently recognized as chlamydospores. The patient was successfully managed with a combination of sinus lavage, oral corticosteroids, itraconazole, and allergen immunotherapy. This case also points out that careful scrutiny of direct smears is required to ensure that fungal structures are not misinterpreted.

Histopathologic assessment of fungal involvement of the paranasal sinuses in Turkey

OBJECTIVE

To assess paranasal sinus material histopathologically for the presence of fungus.

MATERIAL AND METHODS

Paraffin-embedded archival biopsy samples of patients who underwent endonasal sinus surgery between 1992 and 2002 were retrospectively assessed for the presence of fungi. Hematoxylin-eosin-stained sections of the materials were re-evaluated, and Gomori's methanamine silver stain was also applied as required.

RESULTS

Fungus (Aspergillus) was detected histopathologically in only 21476 patients, both of whom were immunocompetent. One patient was considered to have chronic indolent sinusitis and the other allergic fungal sinusitis.

CONCLUSIONS

Although histopathologic assessment is one of the most important diagnostic tools, on its own it may lead to underestimation of fungal involvement of the paranasal sinuses. Alternatively, fungal involvement of the paranasal sinuses may be very infrequent in Turkey.

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.

Isolation of fungi by standard laboratory methods in patients with chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

Allergic fungal sinusitis and the role of fungi in the pathogenesis of chronic rhinosinusitis are topics of interest and controversy in rhinology. The classification of chronic rhinosinusitis as either a bacterial infection or an allergic (eosinophilic) reaction to fungi has significant implications for treatment of this disease process. We designed a study to determine whether standard isolation techniques, as employed in a university hospital mycology laboratory, could isolate and identify fungi in the intraoperative specimens from patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis.

STUDY DESIGN

Forty-five random patients with a diagnosis of chronic rhinosinusitis by clinical and computed tomography criteria underwent endoscopic sinus surgery during 2001, performed by two senior surgeons (J.B.J., R.A.L.). Specimens of mucin, sinus secretions, and/or tissue were obtained intraoperatively and sent to the New York University Medical Center (New York, NY) mycology laboratory for isolation and identification of fungi.

METHODS

Specimens were treated with Sputolysin and chloramphenicol; plated on Sabouraud, ChromAgar/Candida, Mycosel, and Niger seed agar plates; and incubated at 30 degrees C (or 37 degrees C) for up to 1 month.

RESULTS

We were able to demonstrate the presence of fungi in 56% of intraoperative specimens obtained from patients undergoing surgery for chronic rhinosinusitis.

CONCLUSIONS

Using a standard hospital mycology laboratory protocol, which is relatively inexpensive and readily available, fungus can be isolated from a majority of patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. Educational statement: Discuss the possible role of fungus in chronic rhinosinusitis and evaluate the efficacy of documenting the presence of fungus in a routine fashion to encourage clinically relevant directed treatments.)

Comparison of medical and surgical treatment of nasal polyposis

Nasal polyposis is the end result of a variety of pathologic processes. The aims of treatment are to relieve nasal blockage, restore olfaction, and improve sinus drainage. Treating any accompanying rhinitis is also an aim, which requires that medical treatment be given to all patients with an inflammatory problem. Most forms of nasal polyp recur after treatment, whether medical or surgical. There are few direct comparisons of medical and surgical treatment in the literature. Those that exist suggest that most patients should be treated medically, with surgery reserved for patients who respond poorly. Large prospective randomized trials of surgical versus medical therapy are needed in groups of well-characterized patients to determine the optimum approach for each and to decrease relapse rates. Topical corticosteroids are the mainstay of treatment. All patients with inflammatory polyps should receive topical corticosteroid treatment in the long-term, unless there is a compelling contraindication. Adverse effects of surgery are rare but can be devastating. The major side effects of medical therapy are those of oral corticosteroids, which need to be used carefully. The choice of topical corticosteroid is important because long-term use is necessary; the least absorbed should be used. No cost-benefit analysis has been undertaken in this area, although medical therapy is probably cheaper and involves less work/school absence than sinonasal surgery, even when the latter is performed with an endoscope.

Natural history of allergic fungal rhinosinusitis: a 4- to 10-year follow-up

BACKGROUND

Numerous studies have noted the high rate of recidivism after the initial treatment of allergic fungal rhinosinusitis (AFS). Short-term studies have revealed varying recurrence rates based on therapy; however, little is currently known about the long-term natural history of the disease.

OBJECTIVE

Our goal was to address the question of long-term outcomes in AFS patients and make observations about the natural history of the disease.

PATIENTS AND METHODS

Seventeen patients with follow-up ranging from 46 to 138 months were examined and interviewed, and their charts were reviewed. A quality-of-life survey was completed, and blood was drawn to measure immunoglobulin levels.

RESULTS

All patients initially underwent treatment with a combination of surgery, systemic and/or topical corticosteroids, and immunotherapy to pertinent fungal and nonfungal antigens. Normalization of sinonasal mucosa (Kupferberg stage 0) was seen in 5 (29%) of 17 patients, whereas 76% demonstrated either normal or slight mucosal edema (Kupferberg stage 0 or 1). Serologic testing revealed fungus-specific IgE significantly elevated in all 17 patients.

CONCLUSION

The initial choice of therapy did not appear to affect the long-term outcome, and patients tended to be doing well overall. These results suggest that after successful initial treatment and control of AFS, many patients can achieve a quiescent disease state.

The role of infection in chronic rhinosinusitis

Chronic rhinosinusitis is a common condition, yet little is understood about its pathogenesis. Chronic infection traditionally has been considered a significant factor in the etiology and manifestations of chronic rhinosinusitis. Bacteria can be recovered in most cases of chronic rhinosinusitis, most commonly consisting of Staphylococcus species, anaerobes, and in some cases, gram-negative bacteria. Increasing trends toward bacterial resistance have been identified in chronic rhinosinusitis. Recently, a potential role for fungal infection has emerged. A knowledge of the microbiology of chronic rhinosinusitis will help guide treatment, but more research is required to understand further the exact role of infection in the pathophysiology of chronic rhinosinusitis.

Fungus-specific IgG and IgE in allergic fungal rhinosinusitis

OBJECTIVE

Our study goal was to study fungus-specific immunoglobulins G (sIgG) and E (sIgE) in polypoid rhinosinusitis with and without evidence of allergic fungal rhinosinusitis (AFS).

STUDY DESIGN AND SETTING

A prospective analysis was conducted of fungal sIgG and sIgE using a 9-mold RAST panel in 13 AFS, 11 AFS-like, and 27 non-AFS polypoid rhinosinusitis patients. Nonpolyp controls included 17 volunteers with allergic rhinitis and 11 with no atopic history.

RESULTS

All groups had elevated fungal sIgG levels. Polyps, increasing polyp severity, and AFS were associated with elevated fungal sIgG to a greater number of molds. The AFS group had sIgE elevations (>or=class II) to an average of 5 molds versus only 0.1 in the non-AFS polyp group. Total IgE was 971 U/mL versus 64 U/mL, respectively.

CONCLUSIONS

Multiple elevations of fungal sIgE are adequate diagnostic evidence of these fungi when fungal cultures and histologic examinations are negative in diagnosing AFS. The significance of increased fungal sIgG remains unclear.

SIGNIFICANCE

Early recognition of AFS may be facilitated by screening polypoid rhinosinusitis patients with total serum IgE and RAST testing.