Evaluation and treatment of allergic fungal sinusitis. I. Demographics and diagnosis

Allergic Fungal Rhinosinusitis Diagnosis, Management, Associated Conditions, Pathophysiology, and Future Directions: Summary of a Multidisciplinary Workshop

Allergic fungal rhinosinusitis (AFRS) is a unique endotype of chronic rhinosinusitis with nasal polyps (CRSwNP). Despite high recurrence rates and often more severe presenting signs compared with other subtypes of CRSwNP, research dedicated to AFRS has been lacking. Diagnostic criteria are outdated, the mechanistic relationship of AFRS to other associated diseases is unclear, and the pathophysiology of disease and risk factors for recurrence have not been well studied. In December 2023, a multidisciplinary group of rhinologists, otolaryngologists, pulmonologists, allergists, immunologists, scientists, and infectious disease experts met at the National Institute of Health to discuss unmet needs for future AFRS research and care, including patient management, diagnostic criteria, severity, pathophysiology, and related conditions. A summary of these clinical and associated research discussions is included below.

Isolated sphenoid sinus fungal mucoceles: A rare entity with a high propensity for causing neurological complications

Background

Isolated sphenoid sinus fungal mucoceles are extremely rare and potentially associated with visual disturbances, cranial nerve (CN) deficits, or pituitary dysfunction. Their initial symptoms are often absent or nonspecific, and routine examination offers little information, resulting in diagnostic and therapeutic delays. A high index of suspicion and a thorough understanding of their clinical presentation, neuroradiological features, microbiological implications, and complication profile are crucial for early diagnosis and prompt management. We, herein, analyze a series of consecutive cases of isolated sphenoid sinus fungal mucoceles whom we treated, add to the currently existing published cases, and review the pertinent literature.

Methods

From the databases of endoscopic endonasal skull base and rhinological surgical procedures maintained by our groups, all cases with isolated sphenoid sinus fungal mucoceles were retrieved and included in the study. Clinical and radiological findings, histopathologic evidence of fungal rhinosinusitis, culture results, clinicopathological designation, treatment details, and outcome of CN neuropathies were analyzed.

Results

Headache was the most common symptom (seven cases). Oculomotor (three cases) and abducens (two cases) nerve palsies were encountered in five out of eight patients. Visual loss was seen in two cases. Hypopituitarism was seen in one case. All patients underwent endoscopic endonasal wide bilateral sphenoidectomy. CN palsies improved in four out of five cases.

Conclusion

Endoscopic endonasal wide sphenoidectomy is the surgical treatment of choice and should be performed in a timely manner to prevent permanent sequelae. Histopathological and microbiological examination findings should both be obtained as they dictate the next steps of therapeutic intervention.

Allergic fungal rhinosinusitis and eosinophilic mucin chronic rhinosinusitis: Differential diagnostic criteria. A two-center comparative study following STROBE methodology

OBJECTIVES

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.

MATERIALS AND METHODS

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.

RESULTS

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).

CONCLUSION

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.

Incidence and Prevalence of Fungal Sinusitis in Cases of Chronic Rhinosinusitis

To study the incidence and prevalence of fungal sinusitis and its variants in cases of chronic rhinosinusitis in department of ENT and Head and Neck surgery. The study group consisted of 100 patients of chronic rhinosinusitis attending the outpatient and inpatients in department of Otorhinolaryngology. History was taken and diagnostic nasal endoscopy was performed. Patients underwent endoscopic sinus surgery and systemic treatment when required. Pre surgery serum IgE and post-surgery Histopathology was sent. Out of 100 patients, Males > Females and median age was 45.50 years (range 34.25-59.25 years). On DNE, 88% had polyps with 88.1% males and 87.8% females in their respective groups. 47% had allergic mucin with 49.2% males and 43.9% females in their respective groups. 34% had discharge with 28.8% males and 41.5% females in their respective groups. 37% had fungal filaments with 37.3% males and 36.6% females in their respective groups. 26% had fungal sinusitis in our study among which 53.8% were males and 46.1% were females. Peak fungal sinusitis was in 3rd to 5th decade. Commonest organism isolated was Aspergillus. Serum IgE was higher in patients with fungal sinusitis and nasal polyposis. In conclusion, the proportion of patients with Fungal Sinusitis was 26% among 100 patients with chronic rhinosinusitis. We isolated Aspergillus as the predominant fungus followed by Biporalis and Mucorales genus. Serum IgE was higher in patients with fungal sinusitis and Nasal polyposis. Both immunocompromised and competent individuals were managed surgically and/or medically when required. Our study showed that early fungal sinusitis detection leads to better management practices and prevents its progression into more severe disease with complications.

Chronic Granulomatous Invasive Fungal Sinusitis in Patients With Immunocompetence: A Review

OBJECTIVE

We aimed to study the literature on chronic granulomatous invasive fungal sinusitis to elucidate the changing trends in the management of the disease.

DATA SOURCES

Using specific keywords, we searched the PubMed, PubMed Central, and Scopus databases over the past 50 years, which yielded 938 articles in the English language.

REVIEW METHODS

Scrutiny of 147 relevant articles revealed 15 homogenous case series (255 cases of histologically proven chronic granulomatous fungal sinusitis alone) and 8 heterogeneous case series (patients with other types of fungal sinusitis included), which were analyzed in detail (all with >5 cases each).

CONCLUSIONS

The disease typically affected middle-aged adults with immunocompetence. Most reports were from Sudan, India, and Saudi Arabia. A slowly progressive orbital, cheek, or palatal mass with proptosis (88.2%) or sinonasal symptoms (39.2%) was typical. Ethmoid (57.2%) and maxillary (51.4%) sinuses were chiefly affected with intracranial extension in 35.1%. Aspergillus flavus (64%) was the most frequent isolate reported. Endoscopic excision (78.8%) followed by azole therapy was the preferred treatment in recent reports. Orbital exenteration and craniotomy were infrequently performed. Complete resolution or improvement was reported in 91.3% of patients. Mortality ranged from 5.9% to 22.2%. There is a trend in the literature toward less radical and disfiguring surgery and preferential use of azoles, with good outcomes even in advanced cases.

IMPLICATIONS FOR PRACTICE

Chronic granulomatous fungal sinusitis should be diagnosed on the basis of well-defined histopathologic features. A combination of endoscopic sinus surgery and azole therapy usually yields good outcomes.

Pediatric Allergic Fungal Rhinosinusitis: Does Age Make a Difference?

Background Allergic fungal rhinosinusitis (AFRS) is a hypersensitive response to fungi within the sinus cavity. Children represent a challenging group of patients with sinonasal disorders, as their sinus anatomy is not fully developed. This study aimed to determine the various clinical manifestations and management outcomes in children with AFRS. Methods A retrospective chart review of children who underwent sinus surgery for AFRS at a tertiary healthcare center between 2005 and 2021 was performed. Demographics, clinical manifestations, radiological and laboratory results, treatment regimens, complications, and recurrence rates were collected. Subanalysis was performed based on age at first surgery: group A (<13 years) and group B (≥13 years). Results Overall, 35 children underwent sinus surgery for AFRS during the study period. The mean patient age at the time of surgery was 14 years. Bilaterality was present in 15/35 (42.9%) patients and anosmia in 12/35 (34.3%). Polyps on examination were present in 31/35 (88.6%) patients and proptosis in 8/35 (22.9%). Sub-analysis revealed that group A showed less bilateral disease (11.4%) than group B (31.4%) and a lower Lund-Mackay score (median=11.50 and 17, respectively, p=0.002). Conclusion Age at surgery did not have an impact on the outcome. A high index of suspicion should be exercised when dealing with children with sinonasal symptoms that do not respond to routine treatment and should be investigated for chronic sinusitis.

Characteristics of Chronic Rhinosinusitis with Nasal Polyps Based on Allergic Mucin and Fungal Elements in Patients Undergoing Revision Endoscopic Sinus Surgery

This study sought to document the features in chronic rhinosinusitis with nasal polyp (CRSwNP) patients undergoing revision endoscopic sinus surgery (RESS), based on presence or absence of allergic mucin (AM) and fungal elements (F). A retrospective chart review of RESS cases collected Lund Mackay score (LMS), endoscopic, microbiological, histopathological, surgical and follow-up data of these patients. Patients were categorised into AM + F +, AM + F-, AM-F + and AM-F- subgroups based on the presence or absence of AM and F. The total serum IgE was significantly higher (p > 0.001) in the AM + F + subgroup. Other factors analysed including LMS, duration from previous surgery, comorbidities, degree of inflammation and disease recurrence showed no specific predilection among subgroups. Patients with a retained middle turbinate showed lesser (p = 0.04) recurrence on follow-up. Subgroups of recurrent CRSwNP showed similar characteristics and had further disease recurrence which was independent of allergic mucin and fungal elements. The presence of an intact healthy middle turbinate could reduce early disease recurrence following RESS.

Nasopharyngeal bacterial and fungal microbiota in normal horses and horses with nasopharyngeal cicatrix syndrome

Background

The nasopharyngeal bacterial and fungal microbiota of normal horses and those with nasopharyngeal cicatrix syndrome (NCS) are unknown.

Hypotheses/Objectives

To describe the microbiota from nasopharyngeal washes of healthy horses and of horses acutely affected with NCS.

Animals

Twenty‐six horses acutely affected with NCS horses and 14 unaffected horses.

Methods

Prospective, observational cohort study. Horses were recruited by investigators through personal communications in central Texas. Bacterial (16s RNA) and fungal (internal transcribed spacer) microbiota from nasopharyngeal washes were evaluated. Polymerase chain reaction for detection of Pythium insidiosum was performed.

Results

Results indicated that 6 fungal genera (Alternaria, Bipolaris, Microascus, Spegazzinia, Paraconiothyrium, Claviceps) and 1 bacterial genera (Staphylococcus) were significantly different between affected and unaffected horses. The fungal genus Bipolaris had increased abundance in NCS affected horses and on NCS affected farms. Pythium insidiosum was absent in the nasopharyngeal wash of all horses, irrespective of health status.

Conclusion and Clinical Importance

Significant differences were identified in the fungal microbiota in horses affected with NCS and farms affected with NCS compared to those unaffected. Therefore, Bipolaris warrants further investigation.

Pediatric allergic fungal rhinosinusitis with extensive intracranial extension - Case report and literature review

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Allergic fungal sinusitis (AFRS) has become increasingly common. It’s defined as a noninvasive, benign inflammatory fungal disease of the sinuses which develops in young adults and adolescents.

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AFRS can present clinically in different ways. Its presentation can range from simple nasal obstruction to signs and symptoms of intra-orbital and/or intracranial complications.

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In pediatric cases being very aggressive, Careful clinical evaluation, detailed histopathological examination to rule out mixed types and malignancies.

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Lifelong follow up should be done to manage the recurrence.

Introduction

Over the last two decades, allergic fungal sinusitis (AFRS) has become increasingly common. It’s defined as a noninvasive, benign inflammatory fungal disease of the sinuses which develops in young adults and adolescents. Patients often complain of symptoms like nasal obstruction, congestion, purulent or clear rhinorrhea, anosmia, and headache. The cases are also presenting clinically with symptoms like epiphora and eye discharge as a result of nasolacrimal gland obstruction. In this article, we will review a unique case of AFRS, in an adolescent male. The case was diagnosed with intracranial extradural extension.

Case report

A 15 years old male with AFRS was diagnosed and managed. The case was diagnosed to have allergic fungal sinusitis based on Bent and Khun diagnostic criteria, presented with intracranial extradural extension.

Discussion

In our case, there were no irreversible complications except a recurrent polyp. The case was mainly complaining of long-standing nasal discharge and on-off headache with no orbital complaint and no other neurological signs. This shows a presentation of the fungal sinusitis and the need for aggressive intervention for AFRS both medically and surgically for pediatric patients as well.

Conclusion

To conclude, despite AFRS being categorized as a benign, non-invasive disease, its presentation can range from simple nasal obstruction to signs and symptoms of intraorbital and/or intracranial complications; with pediatric cases being very aggressive. Careful clinical evaluation, detailed histopathological examination, navigation assisted endoscopic sinus surgery followed by steroid treatment, and a lifelong follow up to manage the recurrence.

Bone Regeneration in Allergic Fungal Rhinosinusitis: Post-treatment Image Follow Up

Background: Bone erosion is a feature of allergic fungal rhinosinusitis (AFRS). The incidence of bone regeneration after treatment is unknown. The objective of this study is to evaluate the fate of bone erosion in AFRS.

Materials and methods: A retrospective chart review was conducted for all AFRS patients who had preoperative evidence of bone erosion on the computed tomography (CT) of the paranasal sinus (PNS) and at least one postoperative image. We used the bone erosion score (BES) as a valid tool to evaluate the preoperative bone erosion extension and the rate of regeneration on postoperative images.

Results: A total of 40 patients met our enrollment criteria. Of these, 30 patients underwent CT within nine months postoperatively (mean baseline BES: 9.07, SD: 8.11), 33 patients underwent CT between nine and 18 months postoperatively (mean baseline BES: 9.36, SD: 8.80), and 34 patients underwent CT after 18 months postoperatively (mean baseline BES: 8.56, SD: 7.69). The BES improved by 88.92% within nine months postoperatively with a follow-up BES of 0.93 (SD: 1.65), by 90.29% between nine and 18 months with a follow-up BES of 0.91 (SD: 2.15), and by 96.57% after 18 months with a follow-up BES of 0.29 (SD: 0.62). Complete bone regeneration occurred in 27 patients (67.50%); this was noted within nine months in 21 patients and after 18 months in six. Among them, 16 were male and 11 were female (p = 0.75). Regarding their ages, eight were pediatric and 19 were adult patients (p = 0.31).

Conclusion: Bone erosion in AFRS is a mostly reversible process. Complete bone regeneration occurred in more than two-thirds of patients within a short period of time.

Allergic fungal rhinosinusitis accompanied by allergic bronchopulmonary aspergillosis: A case report and literature review

BACKGROUND

Concomitant allergic fungal rhinosinusitis (AFRS) and allergic bronchopulmonary aspergillosis (ABPA) are extremely rare, with no more than 20 cases reported in the English literature.

CASE SUMMARY

A 52-year-old female patient complained of right-sided nasal obstruction, rhinorrhea, sneezing, epistaxis, and hyposmia for a period of around 5 mo. Nasal examination detected paleness and edema of the nasal mucous membrane and a polyp in the right middle meatus. A computed tomography (CT) scan of the sinuses revealed a ground-glass opacity filling the right maxillary and ethmoid sinuses, along with bone absorption in the medial wall of the right maxillary sinus. Magnetic resonance images were obtained with T1-weighted, T2-weighted, and gadolinium-enhanced T1-weighted sequences. A well-defined mass, located in the right maxillary and ethmoid sinuses and displaying obvious hypointense features, was observed on both T1- and T2-weighted images, with peripheral enhancement on gadolinium-enhanced T1-weighted images. The patient also has a 20-year history of cough and dyspnea. Chest CT revealed columned and cystiform bronchiectasis in the bilateral bronchus, surrounded by a large number of spotted and funicular high-density lesions. The level of serum total IgE was > 5000 kU/L. Serum IgE levels related to house dust and aspergillus showed a positive result, with the values being 3.5 kU/L and 1.2 kU/L. We performed functional endoscopic sinus surgery under local anesthesia. After surgery, topical glucocorticoids and saline irrigation were applied in the nasal cavity until the present time. An oral glucocorticoid (methylprednisolone 16 mg/d) and antifungal agent (itraconazole 200 mg/d) were also used for a period of 4 wk. Montelukast was prescribed at 10 mg/d until the present time. An endoscopic examination showed that the patient was recovering well at 3 mo after surgery.

CONCLUSION

Since different specialists treat ABPA and AFRS, their coexistence may be overlooked. AFRS accompanied by ABPA requires surgical therapy combined with medical control to improve the symptoms.

Low Incidence of Allergic Fungal Rhinosinusitis in Japanese Patients

Background:

Allergic fungal rhinosinusitis (AFRS) is a noninvasive fungal disease of the sinuses with a very high recurrence rate. A very small number of Japanese cases have been reported.

Material and methods:

The subjects were 6 patients with AFRS out of 429 patients who underwent endoscopic sinus surgery at Kagawa Rosai Hospital between December 2011 and November 2017. We retrospectively examined the clinical features and outcomes of these 6 patients.

Results:

The incidence of AFRS was 1.4% (6/429). Allergic fungal rhinosinusitis was unilateral in 5 cases and bilateral in 1. Computed tomography revealed hyperdense areas representing allergic mucin, but no patient exhibited bone erosion. Magnetic resonance imaging showed hypointense or no signal regions at the locations of allergic mucin. Postoperatively, 1 patient developed recurrence. Because the recurrent patient had no significant symptoms, he refused further surgery and received drug therapy. Preoperative eosinophil counts and total IgE levels were elevated in all patients; postoperatively, both remained high in the patient who developed recurrence. Postoperative treatments included steroid therapy and nasal irrigation.

Conclusions:

Allergic fungal rhinosinusitis is less prevalent in Japan than in Western nations. Peripheral blood eosinophil and serum IgE values may be used as the biomarkers.

Significance:

Allergic fungal rhinosinusitis is prone to recurrence. Postoperative treatment including steroid therapy is important in the management of AFRS.

Chronic Rhinosinusitis: Does Allergy Play a Role?

A few chronic rhinosinusitis (CRS) variants have demonstrated a strong association with environmental allergy, including allergic fungal rhinosinusitis (AFRS) and central compartment atopic disease (CCAD). However, the overall relationship between CRS and allergy remains poorly defined. The goal of this review is to evaluate the relationship between CRS and allergy with a focus on specific CRS variants.

Role of preoperative versus postoperative itraconazole in allergic fungal rhinosinusitis

Antifungals used as adjuvant to surgery in AFRS (Allergic Fungal Rhinosinusitis) have shown varying success in delaying recurrences. Itraconazole has been used both as preoperative and postoperative adjuvant. This study investigates the role of itraconazole in AFRS and compares its role between preoperative and postoperative administration of the drug. Patients were randomly divided into groups as: Group 1 (n = 25), received 4 weeks itraconazole in the preoperative period and operated subsequently, Group 2 (n = 25), received 4 weeks itraconazole in the postoperative period, Group 3 (n = 50), matched patients of AFRS, who didn't receive itraconazole. All the groups received oral steroids in tapering doses staring from 1 mg/kg for 6 weeks in the postoperative period. Symptomatic (SNOT 20), radiologic (Lund Mackay, LM) scores and endoscopic (Kupferberg's NE Grades) were noted. Primary postoperative follow-up was for 24 weeks with routine CT scans and nasal endoscopies, followed by which all the patients were followed with nasal endoscopies only with CT scans when required. Both preoperative and postoperative itraconazole showed significant improvement in the SNOT, LM, and Kupferberg's grades in the follow-up period. Preoperative itraconazole therapy showed significantly better results compared to postoperative itraconazole therapy though the recurrence rates were similar in both groups. Itraconazole is a better preoperative adjunct in AFRS than postoperative.

Treatment of Allergic Fungal Sinusitis with High-Dose Itraconazole

Background

Since its original description in the early 1980s, our understanding of allergic fungal sinusitis (AFS) has continued to evolve. The goal of this research was to characterize the typical AFS patient and describe a treatment protocol using endoscopic sinus surgery, high-dose itraconazole, low-dose bursts of oral corticosteroids, and topical corticosteroids.

Methods

A 12-year retrospective chart review was conducted to extract demographic and management data on 139 patients meeting the AFS criteria of atopy, characteristic radiographic findings, eosinophilic mucin, nasal polyposis, and a positive fungal culture or stain.

Results

The typical AFS patient presented at 42.8 years of age, was female, and had 3.5 positive fungal cultures over an average of 31.4 months of follow-up. Although 69 patients (50.3%) experienced recurrence, reoperation was required in only 17 (20.5%) of 83 patients initially managed by our protocol. There were no serious adverse effects attributed to itraconazole over the 36,000 doses prescribed.

Conclusion

The use of itraconazole, short-burst low-dose oral corticosteroids, topical corticosteroids, and endoscopic surgery is a safe and clinically effective regimen in the management of AFS. Our clinical experience suggests medical management of recurrent AFS with itraconazole may avoid revision surgery.

Fungi-Induced Upper and Lower Respiratory Tract Allergic Diseases: One Entity

Introduction:Aspergillus can cause different allergic diseases including allergic bronchopulmonary aspergillosis (ABPA) and allergic fungal rhinosinusitis (AFRS). ABPA is allergic pulmonary disease against Aspergillus antigens. AFRS is a type of chronic rhinosinusitis (CRS) presented as hypersensitivity reactions to the fungal presence in sinuses. The aim of the present study was to clarify if ABPA and AFRS could be considered as a common disease entity.

Methodology: The prospective cohort study included 75 patients with ABPA. Patients were divided into two groups and compared with each other: (i) patients with CT confirmation of rhinosinusitis and presence of fungi in sinuses (ABPA+AFRS group) and (ii) patients without CT or without mycological evidence of AFRS (ABPA group).

Results: Findings of this study were: (i) AFRS was confirmed in 80% of patients with ABPA; (ii) all ABPA+AFRS patients had allergic mucin while fungal hyphae were present in 60% sinonasal aspirate; (iii) ABPA+AFRS patients had more often complicated CRS with (nasal polyps) NP (p < 0.001) and more severe forms of CRS; (iv) culture of sinonasal aspirate revealed fungal presence in 97% patients with ABPA+AFRS; (v) patients with ABPA+AFRS had more common positive skin prick test (SPT) for A. fumigatus (p = 0.037), while patients without AFRS had more common positive SPT for Alternaria alternata and Penicillium notatum (p = 0.04 and p = 0.03, respectively); (vi) 67% of ABPA patients had Aspergillus induced AFRS; (vii) larger number of fungi was isolated from the air-samples obtained from homes of patients with ABPA+AFRS than from the homes of patients without AFRS, while the most predominant species were A. fumigatus and A. niger isolated from almost 50% of the air-samples.

Conclusion: The pathogenesis of ABPA and AFRS is similar, and AFRS can be considered as the upper airway counterpart of ABPA. Fungi-induced upper and lower respiratory tract allergic diseases present common entity. Next studies should clarify the mechanism by which fungi turn from “normal flora” into trigger of immunological reactions, resulting in ABPA or AFRS as well as to find new approaches for its' diagnosis and treatment.

Eosinophilic Otitis Media: the Aftermath of Eosinophil Extracellular Trap Cell Death

PURPOSE OF REVIEW

Eosinophilic otitis media (EOM) is a refractory disease characterized by the accumulation of eosinophils in middle ear effusion and mucosa. We summarize current knowledge regarding the clinical characteristics and management of EOM. Although eosinophil activation in inflamed foci is involved in the pathogenesis of EOM, little is known about the fate of the eosinophils and aftermath of their cell death. We discuss the possibility that eosinophils undergo non-apoptotic cell death that worsens tissue damage and increases effusion viscosity.

RECENT FINDINGS

Unlike chronic otitis media, EOM is strongly associated with an allergic background. Corticosteroids are currently the only effective pharmacological treatment, and surgical intervention is often required. Mucosal eosinophils infiltrate extensively into the middle ear cavity where they are stimulated by locally produced activators including interleukin-5 and eotaxin. The eosinophils undergo cytolysis in the effusion, which represents a major fate of activated eosinophils in vivo. Recent data revealed cytolysis could be renamed as extracellular trap cell death (ETosis). ETosis represents suicidal cell death involving total cell degranulation and development of sticky chromatin structures (extracellular traps (ETs)). The characteristics of eosinophil- and neutrophil-derived ET polymers might contribute to the difference in viscosity of secretions between EOM and common chronic otitis media. The extracellular products remaining after eosinophil ETosis are an important aspect of EOM pathology. The concept of ETosis also has novel implications for potential therapeutic modalities in various eosinophilic disorders.

Identification of fungal causative agents of rhinosinusitis from Mashhad, Iran

Background and Purpose:

Rhinosinusitis is a common disorder, influencing approximately 20% of the population at some time of their lives. It was recognized and reported with expanding recurrence over the past two decades worldwide. Undoubtedly, correct diagnosis of fungi in patients with fungal rhinosinusitis affects the treatment planning and prognosis of the patients. Identification of the causative agents using the standard mycological procedures remains difficult and time-consuming.

Materials and Methods:

Based on clinical and radiological parameters, 106 patients suspected of fungal rhinosinusitis were investigated in this cross-sectional prospective study from April 2012 to March 2016 at an otorhinolaryngology department. In this study, internal transcribed spacer (ITS) and calmodulin (CaM) sequencing were respectively validated as reliable techniques for the identification of Mucorales and Aspergillus to species level (both agents of fungal rhinosinusitis).

Results:

Of these, 63 (59.4%) patients were suspected of allergic fungal rhinosinusitis (AFRS), 40 (37.7%) patients suspected of acute invasive fungal rhinosinusitis (AIFRS), and 3 (2.8%) patients suspected of mycetoma. In patients suspected of AFRS, AIFRS, and mycetoma only 7, 29, and 1 had positive fungal culture, respectively. After ITS and CaM sequencing, Aspergillus flavus was the most common species isolated from non-invasive forms, and A. flavus and Rhizopus oryzae were more frequently isolated from invasive forms.

Conclusion:

Aspergillus flavus is the most common agent of fungal rhinosinusitis in Iran, unlike most other reports from throughout the world stating that A. fumigatus is the most frequent causative agent of this disease.

Eosinophil ETosis and DNA Traps: a New Look at Eosinophilic Inflammation

The traditional paradigm of eosinophils as end-stage damaging cells has mainly relied on their release of cytotoxic proteins. Cytokine-induced cell survival and secretion of granular contents from tissue-dwelling eosinophil are thought to be important mechanisms for eosinophilic inflammatory disorders, although the occurrence of cytolysis and its products (i.e., free extracellular granules) has been observed in affected lesions. Recent evidence indicates that activated eosinophils can exhibit a non-apoptotic cell death pathway, namely extracellular trap cell death (ETosis) that mediates the eosinophil cytolytic degranulation. Here, we discuss the current concept of eosinophil ETosis which provides a new look at eosinophilic inflammation. Lessons from eosinophilic chronic rhinosinusitis revealed that ETosis-derived DNA traps, composed of stable web-like chromatin, contribute to the properties of highly viscous eosinophilic mucin and impairments in its clearance. Intact granules entrapped in DNA traps are causing long-lasting inflammation but also might have immunoregulatory roles. Eosinophils possess a way to have post-postmortem impacts on innate immunity, local immune response, sterile inflammation, and tissue damage.

[Fungal sinusitis]

Although sinusitis affects about 20 % of the population, fungal sinusitis is rare. Aspergillus sp. are most frequently implicated. Fungal sinusitis represents a wide spectrum of disorders, including acute or chronic and invasive or non-invasive forms. Invasive fungal sinusitis may develop in an immunocompromised or diabetic patient, whereas non-invasive fungal sinusitis should be considered in a chronic situation, resistant to antibiotics in immunocompetent patients. Allergic fungal sinusitis is related to hypersensitivity of the host to the fungus. The diagnosis of these infections requires radiological examination and endoscopy with mucosal biopsies examined histologically and mycologically in order to distinguish the different types of sinusitis. In the non-invasive forms, surgical treatment is essential, sometimes combined with antifungal and anti-inflammatory treatment. The invasive forms require antifungal treatment, combined with surgery in some forms, particularly mucormycosis.

Ethmoid malformation associated with pediatric nasal polyposis and allergic fungal sinusitis

A 17-year-old female with allergic fungal sinusitis and nasal polyposis presented with epistaxis in the emergency room. On examination, right-sided proptosis and irregular nasal obstruction were observed in the right nasal cavity. CT imaging revealed massive right-sided polyposis and significant ipsilateral malformation with boney architecture preservation of the ethmoidal labyrinth and lamina papyracea. The patient was treated surgically with symptomatic improvement. These findings indicate a unique malformation of the ethmoid while the patient was in development. To the authors’ knowledge, this anatomical malformation has not been previously described in the literature. Physicians should implement diagnostic procedures early if nasal polyposis and allergic fungal sinusitis is suspected in pediatric patients, especially with periocular involvement, to mitigate the risk of boney malformations of the sinuses.

Allergic Aspergillus Rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is a unique variety of chronic polypoid rhinosinusitis usually in atopic individuals, characterized by presence of eosinophilic mucin and fungal hyphae in paranasal sinuses without invasion into surrounding mucosa. It has emerged as an important disease involving a large population across the world with geographic variation in incidence and epidemiology. The disease is surrounded by controversies regarding its definition and etiopathogenesis. A working group on "Fungal Sinusitis" under the International Society for Human and Animal Mycology (ISHAM) addressed some of those issues, but many questions remain unanswered. The descriptions of "eosinophilic fungal rhinosinusitis" (EFRS), "eosinophilic mucin rhinosinusitis" (EMRS) and mucosal invasion by hyphae in few patients have increased the problem to delineate the disease. Various hypotheses exist for etiopathogenesis of AFRS with considerable overlap, though recent extensive studies have made certain in depth understanding. The diagnosis of AFRS is a multi-disciplinary approach including the imaging, histopathology, mycology and immunological investigations. Though there is no uniform management protocol for AFRS, surgical clearing of the sinuses with steroid therapy are commonly practiced. The role of antifungal agents, leukotriene antagonists and immunomodulators is still questionable. The present review covers the controversies, recent advances in pathogenesis, diagnosis, and management of AFRS.

Allergic Fungal Sinusitis: Expanding the Clinicopathologic Spectrum

OBJECTIVE

We sought to determine whether histologic tissue invasion occurs in allergic fungal sinusitis (AFS) and, if so, to identify clinical indicators for the same. Study design and setting We conducted a retrospective case record review of all 28 AFS cases identified by histology over a 32-month period at a tertiary care referral center. All histologic specimens were reevaluated for features of invasive pathology, and case records were correlated for clinical, radiologic, or laboratory parameters associated with such invasion.

RESULTS

In addition to the universal finding of the characteristic allergic mucin with fungal elements on histopathologic examination of the sinus luminal contents, 6 cases (21%) had additional evidence of mucosal invasion as indicated by granulomatous inflammation and branching septate fungal hyphae in the submucosal tissues. Such coexistent invasion was associated with advanced disease as indicated by a higher incidence of orbital involvement on clinical evaluation (P = 0.024), and extrasinus spread (intraorbital or intracranial spread) on the computed tomography evaluation (P = 0.003). The single death that occurred on follow-up was in a patient with coexistent invasion.

CONCLUSION

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

SIGNIFICANCE

The noninvasive and invasive forms of fungal sinusitis are not necessarily discrete and may coexist in the same patient. Clinical features of orbital involvement or computed tomography manifestations of extrasinus spread should alert the clinician to the possibility of invasion.

Efficacy of preoperative itraconazole in allergic fungal rhinosinusitis

INTRODUCTION

Criterion standard treatment of allergic fungal sinusitis (AFS) is primary surgery followed by adjuvant therapy. Even after good surgery, recurrence rates vary from 10 to 79%. Antifungals, e.g., itraconazole, and steroids have shown varying success rates in delaying recurrences given after surgery. Itraconazole decreases the need for steroids given as a primary treatment in allergic bronchopulmonary aspergillosis. This study investigated the efficacy of itraconazole given preoperatively for allergic fungal rhinosinusitis.

METHODOLOGY

A prospective study was carried out from July 2011 to November 2013 with 27 patients with histologically proven AFS, who were given itraconazole for 1 month in the preoperative period and operated after completion of the course of itraconazole. They were compared with 25 matched controls of patients with AFS who were operated on directly without preoperative itraconazole. Both groups were given oral steroids in tapering doses for 6 weeks during the postoperative period and followed up at regular intervals. Evaluations were done by using symptomatic (Sino-Nasal Outcome Test [SNOT-20]), radiologic (Lund Mackay scores), and endoscopic (Kupferberg nasal endoscopic grades) parameters.

RESULTS

Symptomatology scores (SNOT-20) decreased significantly (p = 0.000) with itraconazole. There was a decrease (p = 0.007) in the Lund Mackay scores that reached up to 0. There was complete resolution of disease in 15% of the patients. Reductions in hyperdensities were noted on computed tomography in all the patients after preoperative itraconazole. Polyp sizes decreased and nasal endoscopic grades improved after itraconazole. Postoperative fungal cultures were positive in 60% of the patients in the preoperative itraconazole group compared with 76% of the patients in the control group, which indicated a decreased fungal burden.

CONCLUSION

We found improvements in clinical, radiologic, and endoscopic parameters in AFS after preoperative itraconazole administration, which decreased the disease load significantly and also reduced the extent of surgery in the short-term follow-up. It may prove to be a good preoperative adjunct that needs further research.

Cochliobolus hawaiiensis Sinusitis, a Tropical Disease? A Case Report and Review of the Literature

A sinusitis caused by Cochliobolus hawaiiensis (anamorph: Bipolaris hawaiiensis) was diagnosed in metropolitan France in a patient originating from New Caledonia. The patient completely recovered after surgical treatment consisting in marsupialization of the mucoceles and removal of the fungus balls located in the left nasal cavity and the left maxilla and ethmoid sinuses. One year after, both endoscopic examination and CT scan of the sinuses were normal. Various clinical presentations of diseases associated with C. hawaiiensis have been reported. A review of the literature indicates that although C. hawaiiensis is very rarely reported in Europe, it is one of the major rhinosinusitis agents in areas with a relatively warmer climate, such as India or Southwestern USA. This is the first report of a sinusitis caused by C. hawaiiensis diagnosed in France, with a total recovery outcome.

Categorization and clinicopathological features of chronic rhinosinusitis with eosinophilic mucin in a korean population

Objectives

Chronic rhinosinusitis (CRS) with eosinophilic mucin is relatively rare in Korea. We categorized CRS patients with characteristic eosinophilic mucin into several groups and compared the groups based on their clinicopathological features.

Methods

In total, 52 CRS patients with eosinophilic mucin were enrolled. Based on the presence or absence of an allergy (A) to a fungus or fungal element (F) in the mucin, the patients were divided into four groups: allergic fungal rhinosinusitis (AFRS, A+F+), AFRS-like sinusitis (A+F-), eosinophilic fungal rhinosinusitis (EFRS, A-F+), and eosinophilic mucin rhinosinusitis (EMRS, A-F-). Clinical and immunological variables were compared between the groups.

Results

There were 13 patients in the AFRS group, 13 in the EFRS group, and 26 in the EMRS group. No patient was assigned to the AFRS-like sinusitis group. The AFRS group showed a significantly higher association with allergic rhinitis than did the EFRS and EMRS groups. The mean total serum IgE level in the AFRS patients was significantly higher than in the EFRS and EMRS patients. While 7.7% of the patients with AFRS and EFRS were asthmatic, 65.4% of the patients with EMRS had bronchial asthma. In the AFRS and EFRS groups, 31% had bilateral disease, in contrast to 100% of EMRS patients with bilateral disease. The prevalence of high attenuation areas by computed tomography was significantly higher in the AFRS group than in the EMRS group, and the mean Hounsfield unit values of the areas of high attenuation in the AFRS patients were significantly greater than those in the EMRS patients.

Conclusion

AFRS is believed to be an allergic response to colonizing fungi in atopic individuals. In EFRS, local allergies to fungi may play a role in the pathogenesis of the disease. EMRS is thought to be unconnected with fungal allergies.

Fungal rhinosinusitis: what every allergist should know

The interaction between fungi and the sinonasal tract results in a diverse range of diseases with an equally broad spectrum of clinical severity. The classification of these interactions has become complex, and this review seeks to rationalize and simplify the approach to fungal diseases of the nose and paranasal sinuses. These conditions may be discussed under two major headings: non-invasive disease (localized fungal colonization, fungal ball and allergic fungal rhinosinusitis) and invasive disease (acute invasive rhinosinusitis, chronic invasive rhinosinusitis and granulomatous invasive rhinosinusitis). A diagnosis of fungal rhinosinusitis is established by combining findings on history, clinical examination, laboratory testing, imaging and histopathology. The immunocompetence of the patient is of great importance, as invasive fungal rhinosinusitis is uncommon in immunocompetent patients. With the exception of localized fungal colonization, treatment of all forms of fungal rhinosinusitis relies heavily on surgery. Systemic antifungal agents are a fundamental component in the treatment of invasive forms, but are not indicated for the treatment of the non-invasive forms. Antifungal drugs may have a role as adjuvant therapy in allergic fungal rhinosinusitis, but evidence is poor to support recommendations. Randomized controlled trials need to be performed to confirm the benefit of immunotherapy in the treatment of allergic fungal rhinosinusitis. In this article, we will summarize the current literature, addressing the controversies regarding the diagnosis and management of fungal rhinosinusitis, and focussing on those aspects which are important for clinical immunologists and allergists.

The presence of fungal-specific IgE in serum and sinonasal tissue among patients with sinonasal polyposis

Nasal polyposis (NP) is a common inflammatory disorder with different proposed etiologies. There is some evidence that the local production of specific IgE against fungal allergens may contribute to the pathogenesis of this condition. The aim of this study was to compare local and systemic production of fungal-specific IgE among patients with NP. In a prospective cross-sectional study, 141 patients with sinonasal polyposis who were surgical candidates were enrolled. Total IgE and fungal-specific IgE antibodies in serum and tissue homogenates were measured by the ELISA and ImmunoCAP method, respectively. Twelve cases (9.45 %) met the allergic fungal rhinosinusitis (AFRS) criteria while the remaining 129 patients showed histopathological features of chronic hyperplastic rhinosinusitis. Considering a cutoff point of 0.4 KUI/L for specific IgE as a positive reaction against fungal elements, seven and 62 cases showed positive results in serum and homogenate tissue, respectively. All serum positive reactions were seen among patients with AFRS. In conclusion, IgE antibody could be locally produced in the nasal polyp tissue while not detectable in the serum.

Markers of disease severity and socioeconomic factors in allergic fungal rhinosinusitis

BACKGROUND

Allergic fungal rhinosinusitis (AFRS) is a refractory subtype of chronic rhinosinusitis. There is a paucity of data investigating the association of epidemiologic markers of disease severity. The primary objective of this study is to evaluate components of disease severity with socioeconomic status and health care access.

METHODS

A retrospective analysis was performed on patients diagnosed with AFRS by Bent and Kuhn criteria from 2000 to 2013. Severity of disease was measured by orbitocranial involvement, bone erosion, Lund-Mackay score, serum immunoglobulin E (IgE), and mold hypersensitivity. The North Carolina State Data Center provided county-specific socioeconomic and demographic data. Fisher's exact test, Wilcoxon rank sum test, Pearson correlations, and multivariable linear regression models were used to explore associations between variables.

RESULTS

Of 93 patients, 58% were African American and 39% Caucasian with a male:female ratio of 1.4:1 and average age at presentation of 29 years. Race, age, insurance status, and gender were not associated with severity of disease. Bone erosion was correlated with residence in counties with lower income per capita (p = 0.01). Patients with orbitocranial involvement resided in more rural counties (p = 0.01) with less primary care providers per capita (p = 0.02). Residence in counties with older or poorer quality housing was associated with a higher prevalence of bone erosion (p = 0.02).

CONCLUSION

Within our cohort of patients residing in North Carolina, markers of disease severity (bone erosion and orbitocranial involvement) in AFRS were associated with lower income, rural counties, poor housing quality, and less health care access.

Epidemiology and differential diagnosis of nasal polyps

BACKGROUND

Chronic rhinosinusitis (CRS) is one of the most common chronic medical conditions, with a significant impact on patient quality of life. CRS is broadly classified into two groups: CRS with nasal polyposis (CRSwNP) and CRS without NP (CRSsNP). Clinically, the major subtypes of CRSwNP may be divided into eosinophilic chronic rhinosinusitis (e.g., allergic fungal rhinosinusitis and aspirin-exacerbated respiratory disease [AERD]) and nasal polyps associated with neutrophilic inflammation (e.g., cystic fibrosis [CF]). CF is characterized by mutation of the gene encoding the CF transmembrane conductance regulator. Functional endoscopic sinus surgery is usually required for most NP patients with increased frequency in patients with AERD. This study provides a review of the epidemiology and major classification of CRSwNP.

METHODS

A review was performed of the literature regarding different subtypes of CRSwNP.

RESULTS

Many definitions of CRSwNP exist and estimates of prevalence vary.

CONCLUSION

CRSwNP is a clinical syndrome with a heterogeneous inflammatory profile. Of the subtypes associated with eosinophilic inflammation, AERD remains the most recalcitrant to medical and surgical therapeutic interventions.

Allergic fungal sinusitis and eosinophilic mucin rhinosinusitis: diagnostic criteria

BACKGROUND

Chronic sinusitis is one of the most common otolaryngological diagnoses. Allergic fungal sinusitis and eosinophilic mucin rhinosinusitis can easily be misdiagnosed and treated as chronic sinusitis, causing continuing harm.

AIM

To better identify and characterise these two subgroups of patients, who may suffer from a systemic disease requiring multidisciplinary treatment and prolonged follow up.

METHODS

A retrospective, longitudinal study of all patients diagnosed with allergic fungal sinusitis or eosinophilic mucin rhinosinusitis within one otolaryngology department over a 15-year period.

RESULTS

Thirty-four patients were identified, 26 with eosinophilic mucin rhinosinusitis and 8 with allergic fungal sinusitis. Orbital involvement at diagnosis was commoner in allergic fungal sinusitis patients (50 per cent) than eosinophilic mucin rhinosinusitis patients (7.7 per cent; p < 0.05). Asthma was diagnosed in 73 per cent of eosinophilic mucin rhinosinusitis patients and 37 per cent of allergic fungal sinusitis patients.

CONCLUSION

Allergic fungal sinusitis and eosinophilic mucin rhinosinusitis have the same clinical presentation but different clinical courses. The role of fungus and the ability to confirm its presence are still problematic issues, and additional studies are required.

Immunotherapy for allergic fungal sinusitis

PURPOSE OF REVIEW

Allergic fungal sinusitis (AFS) results from an immunoglobulin E (IgE)-mediated, eosinophil-predominant hypersensitivity reaction to extramucosal fungi within the paranasal sinuses. Although the pathogenesis of this noninvasive process is still not fully understood, there is new information. Recently, the use of allergen immunotherapy with fungal antigens as an adjunct in treatment of AFS has been evaluated. In this review, we summarize the experience in the published literature on the topic.

RECENT FINDINGS

There is evidence to suggest that allergen immunotherapy to fungal allergens may be effective in the treatment of symptoms of AFS and may decrease the rate of postoperative exacerbations and further operations. There is no evidence that this therapy induces immune complex disease. These studies pave the way for controlled trials of immunotherapy in patients with AFS.

SUMMARY

Allergen immunotherapy to fungi shows promise as a treatment to decrease the recurrence of AFS and should be considered a part of the treatment regimen. However, because the number of patients treated has been small and one study suggested that fungal immunotherapy administered before removal of fungal contents from the sinuses could worsen sinusitis, controlled studies are essential to moving forward.

Impact of fungal load on diagnosis and outcome of allergic fungal rhinosinusitis

Fungal load colonization may modify the classic eosinophilic inflammation in allergic fungal rhinosinusitis (AFRS). We aimed to evaluate the impact of fungal load on diagnosis and outcome of AFRS. In the present cohort study fungal load differences were determined prospectively according to Gomori methenamine silver (GMS) fungal stained (histopathological and cytological examination) with the tenacious mucus, cheesy clay-like materials and sinus mucosa/polyps in 12 AFRS patients. Two groups with different fungal loads, AFRS with (six patients) and without (six patients) high fungal loads (HFL) were evaluated for nasal endoscopic score, paranasal sinuses CT score, histopathological and immunohistochemical changes. Endoscopic outcome scoring differences were evaluated for 1 year after endoscopic sinus surgery and 1 month oral corticosteroids treatment. No differences were observed between both groups (AFRS with/without HFL) concerning the total CT score and opacification features (P > 0.05). Eosinophils and CD3 + CD8 + T cell were dominant in both groups. More edema and less fibrosis were observed in HFL group. Gliotoxin producers Aspergilli were present in all HFL in comparison to 5/6 (83.3%) in cases without HFL. Fewer patients 1/6 (16.6%) and less number of recurrences/year 0.1 ± 0.4 occurred in the AFRS with HFL compared to the AFRS without HFL [5/6 (83.3%) and 1.16 ± 0.7) (P = 0.021 and 0.023, respectively]. In addition to mucus and mucosal tissues, cheesy clay-like materials must be assessed in AFRS cases. Although patients of AFRS with HFL had negligible clinical differences from ordinary AFRS without HFL, they had better outcome after treatment.

Allergic fungal sinusitis causing nasolacrimal duct obstruction

INTRODUCTION

Allergic fungal sinusitis is thought to represent a chronic autoimmune reaction directed against fungal elements within the sinuses, and is commonly seen in individuals with a history of chronic sinusitis that is refractory to medical therapy. The authors present a case of allergic fungal sinusitis involving the lacrimal drainage system.

CASE

A 54-year-old woman initially presented with recurrent erythema and induration of the left nasolacrimal sac due to dacryocystitis, which was unresponsive to treatment with topical and systemic antibiotics. Radiological evaluation demonstrated the presence of multiple soft tissue masses along the medial canthi. During subsequent endoscopic dacryocystorhinostomy, significant amounts of allergic mucin were found within the sinuses and marked eosinophilia was present within tissue obtained from the lacrimal sac, findings highly suggestive of allergic fungal sinusitis.

CONCLUSION

A diagnosis of allergic fungal sinusitis should be considered in patients presenting with epiphora in the appropriate clinical context. However, involvement of the lacrimal drainage system is an exceedingly unusual presentation.

Chronic rhinosinusitis

A 50-year-old woman with nonallergic rhinitis, asthma, and aspirin intolerance presented with worsening symptoms of nasal congestion, purulent drainage, and anosmia. Nasal polyps were visualized on anterior rhinoscopy, and there was evidence of chronic rhinosinusitis (CRS) on imaging studies during work-up for another medical condition. Over a 2-year period she had numerous bouts of acute exacerbations of CRS which required multiple courses of antibiotics; however, she was unwilling to undergo surgery to reduce polyp burden. She successfully underwent aspirin desensitization and experienced partial relief of symptoms with daily aspirin ingestion. Nasal obstruction is a common symptom that can result from multiple causes, including mucosal disorders (eg, allergic and nonallergic rhinitis, rhinosinusitis, sarcoid) and structural disorders (eg, nasal septal deviation, tumors, mucoceles). The various causes and work-up for nasal obstruction are discussed with emphasis placed on CRS, which is a prevalent disease characterized by inflammation of the nose and paranasal sinuses for a duration of >12 weeks. The different subtypes of CRS, including CRS with and without nasal polyps, allergic fungal rhinosinusitis, and aspirin-exacerbated respiratory disease, are discussed along with pathogenesis, diagnosis, and treatment options.

Asthenopia as the presenting symptom in advance allergic fungal sinusitis

A 14-year-old male presented to the ophthalmology clinic with a history of asthenopia. Laboratory, radiological and histopathological studies confirmed the diagnosis of allergic fungal sinusitis resulting in lateral displacement of the medial rectus muscles. Symptoms improved and near point of convergence recovered after surgical endoscopic decompression of the ethmoidal and maxillary sinuses.

Fungal rhinosinusitis: a retrospective microbiologic and pathologic review of 400 patients at a single university medical center

Fungal Rhinosinusitis (FRS) is a well known entity, but only in more recent times have the types of FRS been more fully defined. In this study, we evaluate the diagnosis of FRS in a single medical center. Cases were divided into 2 main categories, non-invasive and invasive. Non-invasive FRS included fungus ball (FB) and allergic fungal rhinosinusitis (AFRS). Invasive FRS included acute invasive fungal rhinosinusitis (AIFRS), chronic invasive fungal rhinosinusitis (CIFRS), and chronic invasive granulomatous fungal rhinosinusitis (CGFRS). Fungal culture data, if available was reviewed. 400 patients with FRS were identified. 87.25% were non-invasive (45% AFRS, 40% FB, and 2% combined AFRS and FB and 12.5% were invasive 11% AIFRS 1.2% CIFRS 0.5% CGFRS. One patient (0.25%) had combined FB/CGFRS. Aspergillus sp. or dematiaceous species were the most common fungi isolated in AFS while Aspergillus sp. was most common in FB and AIFRS. In our experience, most FRS is non-invasive. In our patient population, invasive FRS is rare with AIFRS representing >90% of cases. Culture data supports that a variety of fungal agents are responsible for FRS, but Aspergillus sp. appears to be one of the most common organisms in patients with FRS.

The relationship of rhinitis and asthma, sinusitis, food allergy, and eczema

Epidemiologic, genetic, immunologic, and clinical studies show a close relationship between allergic rhinitis and asthma, food allergy, and atopic dermatitis. Rhinitis and sinusitis often coexist and are commonly referred to with the term rhinosinusitis. These conditions are also linked in the so-called atopic march, which is the sequential appearance of atopic manifestations starting with atopic dermatitis and later followed by food allergy, allergic rhinitis, and asthma. Allergic rhinitis and asthma are now increasingly being approached diagnostically and therapeutically as the one-airway concept.

Allergic Aspergillus sinusitis and its association with allergic bronchopulmonary aspergillosis

Allergic Aspergillus sinusitis (AAS) is a three decade old clinicopathologic entity in which mucoid impaction akin to that of allergic bronchopulmonary aspergillosis (ABPA) occurs in the paranasal sinuses. Features such as radiographic evidence of pansinusitis, passage of nasal plugs and recurrent nasal polyposis in patients with an atopic background is suggestive of AAS. Histopathlogic confirmation from the inspissated mucus is a sine qua non for the diagnosis. Heterogeneous densities on computed tomography of the paranasal sinuses are caused by the 'allergic mucin' in the sinuses. Many patients give a history of having undergone multiple surgical procedures for symptomatic relief. The current approach to treatment appears to include an initial surgical debridement followed by postoperative oral corticosteroids for long durations. Although both ABPA and AAS are classified as Aspergillus-related hypersensitivity respiratory disorders, their co-occurrence appears to be an infrequently recognised phenomenon. This could perhaps be attributed to the fact that these two diseases are often treated by two different specialties. A high index of suspicion is required to establish the diagnoses of ABPA and AAS. All patients with asthma and/or rhinosinusitis along with sensitisation to Aspergillus antigens are at an increased risk of developing ABPA and/or AAS. ABPA must be excluded in all patients with AAS and vice versa. Early diagnosis and initiation of appropriate therapy could plausibly alter the course of the disease processes and prevent the possible development of long term sequelae.

Evidence for distinct histologic profile of nasal polyps with and without eosinophilia

OBJECTIVE/HYPOTHESIS

To evaluate the histology, RNA, and protein signatures of nasal polyps (NPs) in order to demonstrate specific subtypes of disease and differentiate "idiopathic" NPs based on tissue eosinophilia.

STUDY DESIGN

Prospective laboratory-based study.

METHODS

NP tissue was obtained from patients referred to the University of Virginia Health System for sinus surgery. Histology analyses included hematoxylin-eosin, Gomori's trichrome, toluidine blue, and chloroacetate staining. RNA and protein were extracted from tissue and cytokine transcript or protein concentrations determined.

RESULTS

Idiopathic NPs can be divided into distinct subsets characterized by absence (NE) and presence (E) of prominent eosinophilia. The validity of this distinction is supported by the demonstration that NE polyps are further distinguished by glandular hypertrophy, dense collagen deposition, and mononuclear cellular infiltrate. In contrast, E-NP display edema, rare glandularity, and minimal collagen deposition except within the basement membrane. Total mast cell numbers were reduced in E-NP, whereas connective tissue mast cells were increased in NE-NP. Consistent with the distinctive pattern of increased fibrosis, NE-NP displayed increased transforming growth factor-β and vascular endothelial growth factor transcripts. Similarly, NE-NPs had higher concentrations of transforming growth factor-β, fibroblast growth factor-β, and platelet-derived growth factor protein.

CONCLUSIONS

Idiopathic NPs can be distinguished by NE and E and are supported by the observations that these display distinct histologic, gene, and protein expression patterns. The findings suggest that as unique diseases, idiopathic NPs will require distinct therapeutic interventions.

Chronic rhinosinusitis: epidemiology and medical management

Chronic rhinosinusitis (CRS) affects 12.5% of the US population. On epidemiologic grounds, some association has been found between CRS prevalence and air pollution, active cigarette smoking, secondhand smoke exposure, perennial allergic rhinitis, and gastroesophageal reflux. The majority of pediatric and adult patients with CRS are immune competent. Data on genetic associations with CRS are still sparse. Current consensus definitions subclassify CRS into CRS without nasal polyposis (CRSsNP), CRS with nasal polyposis (CRSwNP), and allergic fungal rhinosinusitis (AFRS). Evaluation and medical management of CRS has been the subject of several recent consensus reports. The highest level of evidence for treatment for CRSsNP exists for saline lavage, intranasal steroids, and long-term macrolide antibiotics. The highest level of evidence for treatment of CRSwNP exists for intranasal steroids, systemic glucocorticoids, and topical steroid irrigations. Aspirin desensitization is beneficial for patients with aspirin-intolerant CRSwNP. Sinus surgery followed by use of systemic steroids is recommended for AFRS. Other modalities of treatment, such as antibiotics for patients with purulent infection and antifungal drugs for patients with AFRS, are potentially useful despite a lack of evidence from controlled treatment trials. The various modalities of medical treatment are reviewed in the context of recent consensus documents and the author's personal experience.

Allergic fungal sinusitis: innocence under suspicion

The objective of this investigation was to explore the possibility of treating patients harboring invasive intracranial aspergillosis (InIA) at an early stage. Nineteen patients (age range 18-42 years) from a total of 114 cases of InIA seen from January 1999- December 2009 were included in this investigation. These individuals, all of whom had a past history of treated allergic fungal sinusitis (AFS) were evaluated as to their immune status, clinical presentations, time-intervals and radiological findings. Past records of seven patients indicated skull base erosion and extension of the paranasal (PNS) masses into intracranial cavity, but none had neurological deficits or symptoms suggestive of raised intracranial pressure. All 19 patients had undergone endoscopic clearance of PNS during their first presentations. Both AFS and InIA were found simultaneously in seven patients, while the time-interval between the two forms was as long as 10 years for two patients. Overall mortality was (8/19; 42%) with all deaths attributable to fungal meningo-encephalitis. As InIA carries a high mortality rate, it seems prudent to evaluate and treat these patients early in the course of their illness. The appearance of the invasive form of the disease in patients with a past history of AFS is not uncommon. The allergic form of disease may not be considered as a separate entity from InIA as both the pathologies may exist in same patient.