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 Diagnostic criteria are outdated, the mechanistic relationship of AFRS to other associated diseases is unclear, and the pathophysiology of disease and risk factors for recurrence have not been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.

Allergic Fungal Rhinosinusitis and Eosinophilic Chronic Rhinosinusitis Have Different Phenotypes in Japan

BACKGROUND

Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis driven by Types 1 and 3 allergies to fungi. In Japan, it is relatively rare and characterized by prominent eosinophilic infiltration of the sinonasal mucosa, together with eosinophilic mucin containing scattered fungi in the sinus cavity. Eosinophilic chronic rhinosinusitis (eCRS) involves similar eosinophilic infiltration and shares some clinical features with AFRS. However, the clinical differences between eCRS and AFRS remain to be fully elucidated. The aim of this study was to clarify the phenotypes of eCRS and AFRS.

METHODS

This multicenter retrospective study enrolled patients with AFRS and eCRS and compared their clinical parameters. A cluster analysis was conducted to determine the phenotypes of the two diseases.

RESULTS

AFRS patients had a younger age of onset and exhibited milder computed tomography and nasal polyp scores than eCRS patients. Total IgE was significantly higher in AFRS patients than in eCRS patients, while mucosal eosinophil counts were similar. Olfactory disturbances were significantly less severe in AFRS patients compared with eCRS patients. The cluster analysis revealed three phenotypes for AFRS: one that was distinct and independent from eCRS, representing the more classically described AFRS patients, and more the other two that shared characteristics with eCRS.

CONCLUSIONS

AFRS exhibits unique clinical features compared with eCRS. Cluster analysis identified three distinct AFRS phenotypes characterized by CT findings, eosinophilic inflammation, and specific IgE levels against inhaled antigens. These findings underscore the importance of differential diagnosis and personalized treatment strategies for AFRS and eCRS.

Multidisciplinary approach to severe intracranial, intraorbital allergic fungal sinusitis

BACKGROUND

Allergic fungal sinusitis (AFS) is a form of paranasal mycosis that often involves bone destruction and can extend into the orbit and anterior skull base. Intracranial and intraorbital involvement are published but not both in each included patient of a series. The purpose of the present study was to review cases of extensive AFS with orbital or/and skull base erosion, including the presenting symptoms, patient socioeconomic background, imaging features, surgical technique, and post-operative outcomes.

METHODS

The records of 30 patients with the histological diagnosis of AFS and both intracranial and intraorbital involvement were reviewed.

RESULTS

The average age of the patients was 25.2 years. 83 % of patients were male. 70 % were African American. 66 % of patients had Medicaid or were uninsured. Presenting symptoms were headaches (80 %), nasal obstruction (33 %), proptosis (40 %), vision change (23 %), facial pressure (10 %), and decreased sense of smell (7 %). 100 % of patients had bone erosion observed on computerized tomography scans with disease extending intracranially through the anterior skull base or posterior wall of the frontal sinus along with disease that eroded through the lamina papyracea. All patients had failed medical management. All patients underwent surgery by Otolaryngology, Ophthalmology, and Neurosurgery with transnasal endoscopic approaches and orbitotomy. 80 % also underwent a bifrontal craniotomy for removal of intracranial extradural disease with cranialization. 53 % of patients had orbital implants remaining after surgery; 23 % had nasal stents. There were no postoperative cerebrospinal fluid leaks. Average hospital stay was 4.8 days. Preoperatively, 13 % of patients underwent allergy testing. 94 % saw an Allergist postoperatively. 21 % required follow up surgery.

CONCLUSIONS

A team approach of Otolaryngologists, Ophthalmologists, and Neurosurgeons is recommended for this slowly growing but locally destructive disease. Most patients with AFS will present with headaches and nasal obstruction. While most cases of AFS can be successfully managed with transnasal endoscopic techniques, orbitotomy and craniotomy represents an effective treatment for severe AFS cases with extensive intracranial and intraorbital involvement. This disease is found most commonly in young African American males and in the underinsured.

Association between Social Determinants of Health and Allergic Fungal Rhinosinusitis: A Systematic Review and Meta-analysis

OBJECTIVE

Some previous studies have shown an increased prevalence of allergic fungal rhinosinusitis (AFRS) among young, black patients with poor access to health care; however, results have been mixed. The purpose of this study was to investigate the relationship between social determinants of health and AFRS.

DATA SOURCES

PubMed, Scopus, CINAHL.

REVIEW METHODS

A systematic review was performed searching for articles published from date of inception to September 29, 2022. English language articles describing the relationship   between social determinants of health (i.e., race, insurance status) and AFRS as compared to chronic rhinosinusitis (CRS) were selected for inclusion. A Meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted.

RESULTS

A total of 21 articles with 1605 patients were selected for inclusion. The proportion of   black patients among AFRS, chronic rhinosinusitis with nasal polyps (CRSwNP), and chronic rhinosinusitis without nasal polyps (CRSsNP) groups was 58.0% [45.3%-70.1%], 23.8% [14.1%-35.2%], and 13.0% [5.1%-24.0%], respectively. This was significantly higher among the AFRS population compared to both the CRSwNP population (Δ34.2% [28.4%-39.6%], p < .0001) and the CRSsNP population (Δ44.9% [38.4%-50.6%], p < .0001). The proportion of patients who were either uninsured or covered by Medicaid among the AFRS, CRSwNP, and CRSsNP populations was 31.5% [25.4%-38.1%], 8.6% [0.7%-23.8%], and 5.0% [0.3%-14.8%], respectively. This was significantly higher among the AFRS group than the CRSwNP group (Δ22.9% [15.3%-31.1%], p < .0001) and the CRSsNP group (Δ26.5% [19.1%-33.4%], p < .0001).

CONCLUSION

This study confirms that AFRS patients are more likely to be Black and either uninsured or on subsidized insurance than their CRS counterparts.

Climate change, the environment, and rhinologic disease

BACKGROUND

The escalating negative impact of climate change on our environment has the potential to result in significant morbidity of rhinologic diseases.

METHODS

Evidence based review of examples of rhinologic diseases including allergic and nonallergic rhinitis, chronic rhinosinusitis, and allergic fungal rhinosinusitis was performed.

RESULTS

The lower socioeconomic population, including historically oppressed groups, will be disproportionately affected.

CONCLUSIONS

We need a systematic approach to improve healthcare database infrastructure and funding to promote diverse scientific collaboration to address these healthcare needs.

Clinical and radiological evaluation of maxillofacial and otorhinolaryngological manifestations of Hansen's disease

To characterize maxillofacial, otorhinolaryngological and oral manifestations of Hansen's disease (HD), we conducted a cross-sectional study in 21 current patients attending the Unidade Básica de Saúde de Jardim América, Espírito Santo, Brazil and 16 former patients resident at Pedro Fontes Hospital using data from computed tomography imaging, rhinoscopy, and oroscopy. Maxillofacial characteristics were compared with 37 controls. Differences in bone alterations across the three groups were determined mainly by severe resorption/atrophy being more frequent in former HD patients, with severe resorption/atrophy of the anterior alveolar process of maxilla in 50.0% (8/16) of former patients, 28.6% (6/21) of current patients and 10.8% (4/37) of controls and of nasal bones and aperture in 31.3% (5/16) of former patients compared with 0/21 current patients and two controls. There were no substantial differences in otorhinolaryngological and oroscopic findings between the two patient groups. HD patients had more tooth loss than the age-matched control group. Maxillofacial, otorhinolaryngological and oroscopic finding scores were strongly correlated only in current HD patients. Correlation between otorhinolaryngological and maxillofacial scores suggests that protocols for HD patient assessment and follow-up could include otorhinolaryngological evaluation, with radiological imaging where necessary, subject to replication of our findings in a larger study.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Current Concepts in the Management of Allergic Fungal Rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) represents a subtype of chronic rhinosinusitis with nasal polyposis that exhibits a unique, often striking clinical presentation. Since its initial description more than a quarter century ago, a more sophisticated understanding of the pathophysiology of AFRS has been achieved and significant advancements in improving clinical outcomes made. This review focuses on the latest developments involving the pathophysiology and clinical management of this fascinating disease.

Current understanding of allergic fungal rhinosinusitis

Studying the pathophysiology of allergic fungal rhinosinusitis (AFRS) has proved challenging. While this clinical entity is easily distinguishable based on the clinical criteria set forth by Bent and Kuhn twenty-five years ago, studies examining type 2 inflammatory profiles in AFRS can make it seem more alike other CRS subtypes than it is different. Still, evolving research seems to clearly delineate this subtype from others in CRS. This review will critically evaluate the evolution of research examining the pathophysiology of AFRS and will conclude with a summary of the special considerations in the management of this fascinating disease.

Gender-specific differences in serum immunoglobulin E levels and prevalence of fungus in sinonasal tissue noted in patients with chronic rhinosinusitis who underwent endoscopic sinus surgery

BACKGROUND

We previously presented that women with chronic rhinosinusitis (CRS) who elected endoscopic sinus surgery (ESS) have a higher symptom burden than men. Causes of these gender-based differences warranted further study.

OBJECTIVES

To study gender differences in another cohort of adult patients with CRS who underwent ESS and to compare key histopathologic and serologic features Methods: Patients with CRS who underwent ESS (from 2011 to 2014) with structured histopathology reports on surgical samples were studied. The 13-item structured histopathology report detailed key metrics of inflammation and the presence of fungal elements. Clinical, 22-item Sino-Nasal Outcome Test (SNOT-22) score, Lund-Mackay computed tomography (CT) score, serologic (immunoglobulin E [IgE] level, absolute eosinophil count) and histopathologic data were compared between male and female patients by using statistical software.

RESULTS

We studied 130 eligible subjects (mean age, 54.7 years; 49.2% women). Compared with the men, the women had significantly higher preoperative SNOT-22 scores (women, 48.7; men 38.0 [p = 0.004]) but similar CT scores. Serum IgE levels were significantly higher among women versus men (peak, 433.3 versus 190.8 kU/L [p = 0.03]; closest to surgery, 435.0 versus 190.8 kU/L [p = 0.03]). Tissue fungal elements were significantly more prevalent in women versus men (19.0 versus 5.2%; p = 0.02). Up to this point, the analysis was agnostic of clinical details of the subjects. Further analysis was conducted regarding clinical features. Allergic fungal sinusitis (AFS) was found significantly more commonly in the female versus male patients (21.9 versus 9.1%; p = 0.04). Women versus men had a higher prevalence of migraine (19.4 versus 4.6%; p = 0.01) or any primary headache disorders (23.0 versus 6.2%; p = 0.007).

CONCLUSION

Women who underwent ESS for CRS had higher SNOT-22 symptom burden. Worsened symptomatology may be secondary to a higher prevalence of primary headache disorders in women. However, surgeons should also be aware that female patients with CRS who seek ESS may have a higher prevalence of severe disease endotypes (more tissue fungal elements, elevated serum IgE levels) and phenotypes.

Socioeconomic Factors in Allergic Fungal Rhinosinusitis with Bone Erosion

Background

Previous studies have shown an increase in the incidence of orbital and skull base erosion in African Americans and males diagnosed with allergic fungal rhinosinusitis (AFRS). However, underlying reasons for the advanced presentation of AFRS in certain ethnic and gender groups are currently unknown. We evaluated several socioeconomic and demographic factors for their possible contribution to advanced presentation of AFRS in our patient population. Such factors have not been examined previously in the literature. The aim of this study was to evaluate the contribution of race, ethnicity, and various socioeconomic factors to the advanced presentation of AFRS with orbital and skull base bone erosion.

Methods

Retrospective review of medical records and radiological studies were performed for 54 consecutive AFRS patients presenting to a tertiary care rhinology practice. Presence of radiological evidence of bone erosion was compared with demographic data and insurance status, as indicated in the medical record. Bone erosion status was evaluated also against state demographic data, divided by county.

Results

Males were significantly more likely to present with bone erosion than females (p = 0.009). In this analysis, age and race were not statistically associated with the presence of bone erosion. Additionally, no statistically significant correlations were identified between bone erosion and several socioeconomic factors listed from the patient's county of residence (percentage below the poverty level, median household income, population percentage of African Americans, or number of physicians per 1000 residents).

Conclusion

No socioeconomic factors were identified that correlated with the incidence of bone erosion in patients diagnosed with AFRS. Factors other than socioeconomic status and access to health care appear to play a role in the advanced presentation of AFRS.

Association of Socioeconomic Status, Race and Insurance Status with Chronic Rhinosinusitis Patient-Reported Outcome Measures

Objective Disparities in health and health care access are widely prevalent. However, disparities among patients with chronic rhinosinusitis (CRS) are poorly understood. We investigated if CRS severity at presentation according to socioeconomic factors. Study Design Cross-sectional study. Setting Tertiary rhinology center. Subjects and Methods Three hundred prospectively recruited patients presenting with CRS were included. Outcome variables included CRS symptomatology, as reflected by the 22-item Sinonasal Outcome Test (SNOT-22); general health status, as reflected by the EuroQol 5-dimensional visual analog scale (EQ-5D VAS); and CRS-related antibiotic and systemic corticosteroid use. Race/ethnicity, zip code income bracket, education level, and insurance status were used as predictor variables. Regression, controlling for clinical and demographic characteristics, was used to determine associations between predictor and outcome variables. Results Mean SNOT-22 score was 33.8 (SD, 23.2), and mean EQ-5D VAS score was 74.2 (SD, 18.9). On multivariable analysis, presenting SNOT-22 and EQ-5D VAS scores were not associated with nonwhite patient race/ethnicity ( P = .634 and P = .866), education ( P = .106 and P = .586), or the percentage of households in zip code with incomes <$50,000 per year ( P = .917 and P = .979, respectively). SNOT-22 scores did not differ by insurance type, but patients receiving Medicare reported worse general health status. Use of oral antibiotics or oral steroids for CRS was not associated with predictor variables. Conclusion Patients with CRS presented to a tertiary rhinology center with similar metrics for CRS severity and pre-presentation medical management regardless of race/ethnicity, education status, or zip code income level. Patients with Medicare had worse general health status. Further research should investigate potential disparities in diagnosis of CRS, specialist referral, and treatment outcomes.

Incidence of Skull Base and Orbital Erosion in Allergic Fungal Rhinosinusitis (AFRS) and Non-AFRS

OBJECTIVE: To compare the incidence of bony erosion associated with allergic fungal rhinosinusitis (AFRS) with the incidence of bony erosion seen in other types of inflammatory sinusitis.

STUDY DESIGN: Retrospective review.

RESULTS: AFRS was diagnosed in 27 patients, and 15/27 (56%) had bony skull base or orbital erosion. Non-AFRS chronic sinusitis required surgery in 158 patients, but only 8 (5%) had bony skull base or orbital erosion (P < 0.01). AFRS patients were 12.6 times ( P < 0.01) more likely to have bony erosion than non-AFRS patients. African American males were 15.0 times ( P < 0.01) more likely to have bony erosion than whites and African American females combined.

CONCLUSION: Bony erosion with intracranial and intraorbital extension is much more common in AFRS than all other types of inflammatory sinusitis combined. African American males have a higher incidence of AFRS, as well as intracranial and intraorbital extension.

Environmental Risk Factors in Patients with Noninvasive Fungal Sinusitis

Objective. The aim of our study was to try to determine the possible environmental risk factors for noninvasive fungal sinusitis in Egyptian patients. Methods. This is a prospective epidemiological case control study on the environmental risk factors of noninvasive fungal sinusitis. It included 60 patients and 100 age and sex matched controls. Results. There was a statistically significant relation between apartment floor, surface area, exposure to dust, exposure to cockroaches, poor air conditioning, and fungal sinusitis. Yet, no statistical significance was found between allergy related occupations, exposure to animals or plants, although their percentages were higher among cases, smoking, and urban or rural residence. Conclusion. We suggest that for patients with noninvasive fungal sinusitis a change in their living environment must be implied with better exposure to sunlight, larger well ventilated homes, proper cleaning of dust and cockroach extermination, and if possible the judicious use of air conditioners.

Gender-specific differences in chronic rhinosinusitis patients electing endoscopic sinus surgery

BACKGROUND

The objective of this study was to investigate gender-specific differences in chronic rhinosinusitis (CRS) patients electing endoscopic sinus surgery (ESS).

METHODS

This study was a retrospective review of CRS patients electing ESS (2011-2013) at a tertiary-care center.

RESULTS

ESS was elected by 272 patients (mean age 54.6 years; 48.5% female). Mean Lund-Mackay computed tomography (CT) score was 10.9; total 22-item Sino-Nasal Outcome Test (SNOT-22) score was 41.8. Compared to men, women electing ESS had lower CT score (10.1 vs 11.7; p = 0.01) but higher total SNOT-22 score (44.9 vs 39; p = 0.02). Women reported significantly worse postnasal drainage (p < 0.0001) and embarrassment (p = 0.0021). SNOT-22 scores declined with advancing age (women, p = 0.003; men, p = 0.0005). Reduction in CT scores with age was seen only in males (p = 0.03). Stratifying by age, females aged 61 to 80 years had higher SNOT-22 scores compared to male counterparts (p = 0.04), whereas CT scores were similar. More women underwent surgery for CRS without nasal polyps (CRSsNP) (54.9%) whereas more men underwent surgery for CRS with nasal polyps (CRSwNP) (57.4%), but this difference missed statistical significance (p = 0.052). Women with CRSwNP had higher SNOT-22 scores than men (p = 0.02) for similar CT scores. Men electing ESS for CRSsNP had higher CT scores than women (p = 0.02). Women with CRSsNP aged 18 to 40 years reported higher SNOT-22 scores than men (p = 0.003), even though CT scores were lower (p = 0.005).

CONCLUSION

Equivalent numbers of men and women underwent ESS for CRS. Overall, women electing ESS had higher total SNOT-22 scores and lower Lund-Mackay CT scores than men. Women reported more problems with postnasal drainage (CRS overall, CRSsNP, and CRSwNP), embarrassment (CRS overall and CRSwNP), and facial pain (CRSwNP). Gender differences in CRS are poorly understood and merit further study.

Comparison of Socioeconomic and Demographic Factors in Patients with Chronic Rhinosinusitis and Allergic Fungal Rhinosinusitis

OBJECTIVE

The primary objective of this study is to evaluate the differences in socioeconomic, demographic, and disease severity factors between patients with chronic rhinosinusitis (CRS) and those with allergic fungal rhinosinusitis (AFRS).

STUDY DESIGN

A retrospective cohort analysis was performed.

SETTING

The study was conducted at the hospital of the University of North Carolina at Chapel Hill.

SUBJECTS AND METHODS

A total of 186 patients were included (93 AFRS, 93 CRS with and without nasal polyps). Socio- economic and demographic data were obtained from the North Carolina State Data Center. Indicators of disease severity were measured by Lund-Mackay scores, serum immunoglobulin E (IgE) levels, diagnosis of asthma and/or allergic rhinitis, and the number of surgeries and computed tomography scans performed. Associations were analyzed with Fisher's exact, Wilcoxon rank sum, and Pearson's correlations tests.

RESULTS

Compared with patients with AFRS, patients in both CRS groups were predominantly white (P < .0001), were older at the time of diagnosis (P < .0001), had higher county-based income per capita (P = .004), had lower quantitative serum IgE level (P < .001), and had lower Lund-Mackay scores (P < .0001). No associations between disease severity, socioeconomic status, and demographic factors were found within the CRS groups.

CONCLUSION

Within our cohort of patients residing in North Carolina, those with CRS have higher income, more access to primary care, and lower markers of disease severity than those with AFRS. These data continue to support the notion that AFRS merits classification as a distinct subtype of CRS.

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.

Epidemiologic factors and surgical outcomes in patients with nasal polyposis and asthma

BACKGROUND/AIM

To evaluate the role of epidemiologic factors in surgical outcomes for patients with nasal polyposis (NP) and asthma.

METHODS

Data was prospectively collected on patients who underwent endoscopic sinus surgery over a 7-year period. Among patients with chronic rhinosinusitis (CRS) with NP and asthma, surgical outcomes were analyzed according to gender and race.

RESULTS

Patients with NP and asthma had significantly higher Lund-Kennedy and SNOT-20 scores--pre- and postoperatively--compared to CRS patients without NP or asthma. Both Caucasians and African-Americans in the CRS with NP/asthma group showed a statistically significant improvement at 6 months. Caucasians continued to have a significant improvement at 12 months, whereas African-Americans did not. There were no differences according to gender.

CONCLUSION

In our patient population, African-Americans with NP and asthma had poorer outcomes following functional endoscopic sinus surgery.

Chronic rhinosinusitis, race, and ethnicity

BACKGROUND

Little is known regarding the epidemiology of chronic rhinosinusitis (CRS) in racial and ethnic minorities in the United States. This study was designed to comprehensively evaluate the current prevalence of CRS across various treatment settings to identify possible disparities in health care access and use between racial and ethnic populations.

METHODS

The National Health Interview Survey (NHIS), National Ambulatory Medical Care Survey (NAMCS), and National Hospital Ambulatory Medical Care Survey (NHAMCS) database registries were extracted to identify the national prevalence of CRS in race/ethnic populations and resource use in ambulatory care settings. Systematic literature review identified studies reporting treatment outcomes in minority patients electing endoscopic sinus surgery (ESS). Data were supplemented using a multi-institutional cohort of patients undergoing surgical treatment.

RESULTS

National survey data suggest CRS is a significant health condition for all major race/ethnic groups in the United States, accounting for a sizable portion of office, emergency, and outpatient visits. Differences in insurance status, work absenteeism, and resource use were found between race/ethnic groups. Despite its prevalence, few published studies include information regarding minority patients with CRS. Most (90%) cohort studies did not provide details of race/ethnicity for ESS outcomes. Prospective cohort analysis indicated that minority surgical patients accounted for only 18%, when compared with national census estimates (35%).

CONCLUSION

CRS is an important health condition for all major race/ethnic groups in the United States. Significant differences may exist across racial and ethnic categories with regard to CRS health status and health care use. Given current demographic shifts in the United States, specific attention should be given to understanding CRS within the context of racial and ethnic populations. Public clinical trial registration (www.clinicaltrials.gov) I.D. No. NCT00799097.

Aspergillus infections in the head and neck

Aspergillus is a chronic colonizer as well as a nidus of infection in the sinuses and ears. In the sinuses, the severity of the disease is classified by the invasiveness of the infection. Invasive fungal sinusitis varies in its presentation based upon the infective organism and shows reduced morbidity if identified early, which requires a high index of suspicion. Allergic fungal sinusitis was recently further classified using a radiologic staging system and was proven to have symptomatic improvement with the concomitant use of surgery and immunotherapy. Finally, fungal ball appears to be a chronic problem that is usually cured with surgery. Aspergillus in the ear is a relatively common problem often related to prolonged antibiotic use and almost always successfully treated with topical antifungals.

A systematic review of the nasal index and the significance of the shape and size of the nose in rhinology

BACKGROUND

There was great interest in the 19th and early 20th century in classifying human races as Caucasian, Asian African etc. according to nasal shape and size, and the nasal index was the most commonly used measurement to differentiate races.

OBJECTIVE OF REVIEW

To determine if there is any clinical relevance of the shape and size of the nose in relation to physiology, pathology and surgery.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

A structured search of PubMed was performed from 1966 to 2008 for each section of the review focusing on the ethnic variations in nasal index, the effect of climate of nasal shape, ethic variations of nasal physiology and racial predilection for sinonasal pathology.

RESULTS

Nasal proportions do vary between ethnic groups but the size and shape of the nose does not define Caucasian, Asian and African races respectively. Anthropologists agree that the nasal variations are due to man's adaptation to the environment. However, this theory remains to be proven. Published data on nasal physiology have not shown significant differences between the ethnic groups despite obvious differences in nasal proportions. There is no evidence of ethnic specific predilection to disease due to anatomical variation, physiological vulnerability or genetic susceptibility. Rhinology research is often confounded by classifying populations according to race, as racial characteristics are not based on any scientific principles and the nasal index may be a more reliable discriminator. The only area in which the size and shape of the nose is of relevance is in aesthetic and reconstruction surgery.

CONCLUSIONS

Nasal proportions are important aesthetically but appear to have little relevance to the rhinologist.

Localized immunoglobulin E expression in allergic rhinitis and nasal polyposis

PURPOSE OF REVIEW

This article reviews recent literature on local tissue identification of immunoglobulin E (IgE) in various sinonasal inflammatory conditions. Discussions of local IgE expression in allergic and nonallergic rhinitis, atopic and nonatopic sinonasal polyposis, and allergic fungal rhinosinusitis are included.

RECENT FINDINGS

Increased levels of IgE and positive reactivity on nasal allergen provocation tests have been demonstrated in nasal lavage fluid of patients with negative systemic allergy testing. In addition, elevated levels of Alternaria alternata-specific IgE have been identified in nasal polyp patients; this is hypothesized as a contributory factor in the development of nasal polyposis. Further evidence supports the role of local IgE to Staphylococcus aureus superantigens in atopic and nonatopic nasal polyposis. Finally, local IgE specific for a range of antigens has been identified in sinus and inferior turbinate tissue in patients with allergic fungal rhinosinusitis.

SUMMARY

Increased levels of IgE have been identified in sinonasal tissues in allergic and nonallergic rhinitis, atopic and nonatopic sinonasal polyposis, and allergic fungal rhinosinusitis. The ability to identify local tissue IgE in inflammatory sinonasal disease states may have significant diagnostic and therapeutic implications.

Radiologic staging system for allergic fungal rhinosinusitis (AFRS)

OBJECTIVES

1) Develop an objective method for quantifying radiologic bone erosion in allergic fungal rhinosinusitis (AFRS); and 2) assess the utility of the new CT scan staging system in differentiating AFRS patient groups.

METHODS

Patients from two tertiary care rhinology practices with AFRS and available CT scans (1999-2007) were included for review by trained graders. The following novel assessment scale was used: Each paranasal sinus wall with expansion/erosion was scored 1 point, with maximum 3 points possible for each frontal sinus, 2 points for each ethmoid complex, 3 points for each sphenoid sinus, 3 points for each maxillary sinus, and 1 point each for the frontal and sphenoid intersinus septae, yielding maximum of 24 possible points.

RESULTS

A total of 111 CT scans were reviewed. Mean score was 7.8 (range, 0-24). Males scored significantly higher than females (mean, 9.3 vs 5.6, P = 0.001). African Americans scored significantly higher than Caucasians (mean, 9.6 vs 5.0, P < 0.001).

CONCLUSIONS

A scoring system for bone remodeling in AFRS is presented. Males and African-Americans with AFRS demonstrate significantly more bone erosion. Additional analysis of disease course will assess the utility of this staging system in predicting outcomes.

Epidemiology and Medical Mycology of Fungal Rhinosinusitis

Fungal rhinosinusitis (FRS) refers to a spectrum of disease ranging from benign colonization of the nose and sinuses by pathogenic fungi to acute invasive and fatal inflammation extending to the orbit and brain. FRS is classified into two categories: invasive and noninvasive. Invasive FRS may again be subcategorized into acute invasive (fulminant) FRS, granulomatous invasive FRS, and chronic invasive FRS; while noninvasive FRS is subcategorized into localized fungal colonization, sinus fungal ball and eosinophil related FRS (including allergic fungal rhinosinusitis, eosinophilic fungal rhinosinusitis). This classification is not without controversies, and intermediate and semi-invasive forms may also exist in particular patients. Acute invasive FRS is an increasingly common disease worldwide among the immunocompromised patients and caused most frequently by Rhizopus oryzae, and Aspergillus spp. Granulomatous invasive FRS has mostly been reported from Sudan, India, and Pakistan and is characterized by noncaseating granuloma formation, vascular proliferation, vasculitis, perivascular fibrosis, sparse hyphae in tissue, and isolation of A. flavus from sinus contents. Chronic invasive FRS is an emerging entity occurring commonly in diabetics and patients on corticosteroid therapy, and is characterized by dense accumulation of hyphae, occasional presence of vascular invasion, sparse inflammatory reaction, involvement of local structures, and isolation of A. fumigatus. While localized fungal colonization describes the most benign of all fungal sinusitis in the superficial nasal crusts, sinus fungal ball is a dense mycetoma like aggregate of fungal hyphae in diseased sinuses. Common in southern Europe, especially France, majority of them are sterile on culture while 30-50% may yield Aspergillus spp. The definitions and pathogenesis of the group of syndromes in eosinophil related FRS (AFRS, EFRS) are contentious and a matter of intense research among otolaryngologists, pathologists, immunologists and microbiologists. While dematiaceous fungi are the foremost initiators of these syndromes in the west, Aspergillus flavus is the predominant pathogen in India and the Middle-East.

Antigen-specific IgE in Sinus Mucosa of Allergic Fungal Rhinosinusitis Patients

Background

Local tissue production of antigen-specific immunoglobulin E (IgE) has been shown in patients with allergic rhinitis and in patients with chronic rhinosinusitis (CRS) with nasal polyps. In allergic fungal rhinosinusitis (AFRS), specific IgE has been established in nasal lavage fluid and eosinophilic mucin. In this study, local production of antigen-specific IgE within sinus mucosa of AFRS patients was evaluated.

Methods

Sinus mucosa homogenates from 11 AFRS patients, 8 patients with CRS without nasal polyps (CRSsNP), and 9 nonrhinosinusitis control patients were assessed for IgE localization by immunohistochemistry. AFRS and control tissue homogenates were also evaluated for antigen-specific IgE to 14 common antigens by ImmunoCAP testing (Phadia AB, Portage, MI).

Results

There was a significant increase in IgE staining in AFRS sinus epithelium and subepithelium compared with controls and with patients with CRSsNP (p ≤ 0.012 for all group differences). AFRS patients showed increased IgE staining in the subepithelium when compared with epithelium (p < 0.001). AFRS sinus tissue had significantly more IgE measured by ImmunoCAP when compared with control sinus tissue for 7 of 14 specific antigens (p < 0.05) and for total IgE (p = 0.004). Antigens with a significant difference on ImmunoCAP included Cladosporium, Aspergillus, Timothy grass, red maple, cockroach, ragweed, and cocklebur.

Conclusion

AFRS patients showed significantly more IgE in sinus mucosa tissue specimens, with increased IgE in subepithelial sites when compared with epithelium. The increased expression of antigen-specific IgE is not limited to fungal antigens. These findings support the role of type I hypersensitivity and local manifestations of allergy in AFRS patients.

Socioeconomic factors in the diagnosis of allergic fungal rhinosinusitis

Objectives

1) To investigate socioeconomic and demographic factors differentiating allergic fungal rhinosinusitis (AFRS) from other chronic rhinosinusitis (CRS) diagnostic groups. 2) To consider the potential impact of epidemiological differences on AFRS disease course.

Study Design

Retrospective review.

Study Methods

Retrospective review of AFRS patients, CRS patients with nasal polyps (CRSwNP) without AFRS, and CRS patients without polyps (CRSsNP). Analysis of group differences was performed for age at presentation, gender, ethnicity, insurance status, and socioeconomic measures with the use of medical records and a South Carolina demographic database.

Results

AFRS presentation age was lower than CRSwNP and CRSsNP ( P < 0.001). The AFRS group had more African Americans ( P < 0.001) and uninsured or Medicaid patients ( P < 0.001) than expected. AFRS patients resided in counties with higher poverty percentage ( P = 0.011), lower median income ( P = 0.048), and more African American residents ( P = 0.020) than CRSsNP patients. No group differences existed for gender or physicians per 1000 county residents.

Conclusion

Demographic and socioeconomic factors may affect AFRS presentation and treatment.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.