Understanding paediatric allergic fungal sinusitis: Is it more aggressive?

What is appropriate management for the contralateral uninvolved side in unilateral allergic fungal rhinosinusitis?

PURPOSE OF REVIEW

The aim of this article is to review the current literature regarding development of new or recurrent inflammation of uninvolved contralateral sinuses in unilateral allergic fungal rhinosinusitis (AFRS) and discuss management strategies.

RECENT FINDINGS

AFRS is a subtype of chronic rhinosinusitis with nasal polyposis (CRSwNP) that can manifest as either unilateral or bilateral disease. Particular to AFRS compared with other CRSwNP subtypes is the high propensity for recurrence. Multiple recent studies have evaluated the recurrence rate of uninvolved contralateral sinuses in unilateral AFRS and demonstrated eventual involvement of the nondiseased side. Additionally, postoperative medical therapy of the nondiseased side reduced recurrence rates overall.

SUMMARY

Recurrence of AFRS is high in both the ipsilateral and contralateral sinuses. Upfront bilateral medical and/or surgical treatment of patients presenting with unilateral AFRS may be considered to improve long-term inflammatory control.

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.

Pediatric allergic fungal rhinosinusitis: optimizing outcomes

PURPOSE OF REVIEW

Allergic fungal rhinosinusitis (AFRS) is a debilitating condition for children. Despite there being several reviews on this topic in the adult population, there is a paucity of reviews of AFRS in the pediatric literature. This article reviews the recent evidence of pediatric AFRS with the aim to optimize outcomes of pediatric patients with this condition.

RECENT FINDINGS

AFRS is clinically characterized by nasal polyposis, a type I hypersensitivity to fungal epitopes, very thick eosinophilic mucin, and peripheral eosinophilia. Pediatric AFRS has similar clinical characteristics to that in adults but is thought to have a more aggressive nature, with higher serum immunoglobulin E and more frequently bone erosion and malformation of facial bones. Diagnosis of pediatric AFRS is made by using the Bent and Kuhn's criteria developed for adult AFRS. The mainstay of treatment is surgery followed by postoperative corticosteroids. Adjunctive therapies, including topical/oral antifungal agents, allergen immunotherapy and biologics may improve outcomes in pediatric AFRS, but to date the current evidence is limited.

SUMMARY

To optimize the outcome of pediatric AFRS, adequate and early diagnosis and treatment are essential. Appropriate and comprehensive endoscopic sinus surgery to open the sinuses, remove the fungal burden of disease and improve access of the sinuses to postoperative topical corticosteroid remains the standard of care.

Unilateral Exserohilum Allergic Fungal Sinusitis in a Pediatric Host: Case Report

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Exserohilum species are a very rare causative organism in allergic fungal sinusitis (AFS).

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Treatment of AFS consists of medical and surgical modalities.

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AFS in pediatric patients is believed to be more aggressive with a higher recurrence rate.

Introduction

Allergic fungal sinusitis (AFS) is a result of an inflammatory reaction to fungi in the nasal and paranasal sinuses. Although the causative agents of AFS vary, Exserohilum species are among the rare ones, as only a few cases have ever been reported a few times in the literature. The objective of this report is to highlight this unusual fungal type causing unilateral AFS in Saudi Arabia.

Presentation of the case

We present a case of AFS who initially presented at the age of 15 years, and was operated on in 2015 by another health care provider. He presented again in 2019 complaining of intermittent loss of smell and greenish nasal discharge, mainly from the right side for 3 months, which was associated with right-sided nasal obstruction. Based on the history and physical examination, a diagnosis of refractory chronic rhinosinusitis was made. The patient underwent functional endoscopic sinus surgery (FESS) of the paranasal sinuses and polypectomy. Histopathology of the samples taken during the surgery showed Exserohilum specie. The diagnosis of AFS was confirmed using Bent and Kuhn’s criteria.

Discussion

Allergic fungal sinusitis is believed to be an allergic reaction caused by a broad spectrum of species, the majority being Aspergillus in India and Saudi Arabia. Exserohilum species are one of the rare organisms causing AFS in our region.

Conclusion

Most cases of AFS in our region have been reported to be caused by Aspergillus. Here we report a case of unilateral Exserohilum AFS in an immunocompetent pediatric patient.

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.

Clinical Evidence and Biomarkers Linking Allergy and Acute or Chronic Rhinosinusitis in Children: a Systematic Review

Purpose of the Review

We provide a systematic review of experimental and clinical evidences linking allergy to acute, including common cold, and chronic rhinosinusitis in children. Furthermore, we questioned if anti-allergy treatment may prevent the occurrence of rhinosinusitis or improve outcomes of its specific management.

Recent Findings

Allergic rhinitis is a common childhood disease in industrialized countries that is responsible for a major impact on quality of life and healthcare resources. Over the years many authors tried to correlate allergy with comorbidities and in particular to the onset of rhinosinusitis including common cold, even though conflicting results are frequently reached. We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) process. Our search yielded 7103 that were finally screened. This resulted in 25 publications of which the full texts were assessed and included in a qualitative analysis per different phenotypes of rhinosinusitis.

Summary

The evidence suggests that allergy may lead to overall impairment of mechanical and immunological defense function of the nasal mucosa against viruses and that anti-allergy treatment may significantly decrease the number and severity of upper respiratory tract infections including common colds in children. It was not possible to perform the analysis for allergy and post-viral acute rhinosinusitis, bacterial acute rhinosinusitis, and recurrent acute rhinosinusitis because of paucity and heterogeneity of data. Although there is no definitive proof of causation linking allergy to chronic rhinosinusitis, studies lead to suppose that anti-allergy treatment may improve outcomes of specific CRS treatments.

Pediatric alternating allergic fungal rhinosinusitis: A case report and literature review

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Allergic fungal rhinosinusitis nature in children is more aggressive when compared to adults.

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Endoscopic sinus surgery is an important therapeutic step in the treatment of allergic fungal rhinosinusits.

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The reason for this contralateral development of AFRS not clear, but it may be part of the natural disease process.

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Involvement of the contralateral sinuses in children is uncommon. The normal uninvolved sinus should be involved in the routine endoscopic examination and the post-operative treatment in order to minimize the risk of disease recurrence.

Objectives

to report the alternating nature of allergic fungal rhinosinusitis in children in the Eastern part of Saudi Arabia and to review the experience of King Fahad Specialist Hospital in the diagnosis and management of alternating allergic fungal rhinosinusitis in children.

An 8 years old Saudi girl with alternating allergic fungal rhinosinusitis was diagnosed and managed. The patient was diagnosed to have unilateral left allergic fungal rhinosinusitis and underwent endoscopic sinus surgery and cleaning of the left sinuses from polyps, mud and mucin. One year postoperatively the patient developed AFRS in the contralateral right side.

Conclusion

involvement of the contralateral sinuses in children with AFRS is uncommon. The normal uninvolved sinus should be involved in the routine endoscopic examination and the post-operative treatment in order to minimize the risk of disease recurrence.

[Allergic fungal rhinosinusitis: A diagnosis to evoke]

Among fungal infections of the nasal sinuses, allergic fungal rhinosinusitis is a recently described, relatively rare and little known pathology. Its diagnosis is based on: clinical criteria (it occurs in young immunocompetent patients, often associated with bilateral nasosinusal polyposis); pathological criteria (allergic mucin: eosinophilic mucus without invasion of the sinusal mucosa and observation of fungal hyphae on surgical samples); biological criteria (hypereosinophilia, total and specific antifungal IgE); and radiological criteria. The combination of tomodensitometry (heterogeneous hyperdense and diffuse filling of nasosinusal cavities with expanded borders and a distended appearance of the bony wall), and MRI scan (extensive character and lesional signal [hypo and asignal T1 and T2], and cerebriform aspect of the fungal process) strongly suggests the diagnosis. It is important to distinguish the most typical forms, as well as unusual forms of allergic fungal rhinosinusitis. Main differential diagnoses are represented by other forms of fungal nasosinusal infections with different treatment and prognosis.

Effect of nebulized budesonide on decreasing the recurrence of allergic fungal rhinosinusitis

OBJECTIVE

The aim of this study was to evaluate the clinical efficacy and the effects on decreasing the recurrence of AFRS (allergic fungal rhinosinusitis) of a budesonide inhalation suspension delivered via transnasal nebulization to patients following endoscopic sinus surgery.

SUBJECTS AND METHODS

Thirty-five patients were recruited into this study. Final diagnoses were reached using Bent and Kuhn's criteria. The eligible patients were randomly divided into two groups: the budesonide transnasal nebulization group (group A) and the topical nasal steroids group (group B). Nasal symptoms, Lund-Mackay scores, and Kupferberg grades were evaluated before surgery, after surgery and during the follow-up to assess the effects of these two approaches.

RESULTS

A total of 30 patients with AFRS who were eligible were included in the study. Four of the 15 patients in group B (26.67%) developed recurrent disease, whereas no patients in group A developed recurrent disease. This difference was statistically significant (p=0.032).

CONCLUSION

Nebulized budesonide is an effective and safe treatment for patients with AFRS following endoscopic sinus surgery, as evidenced by the reduced recurrence rate observed in the budesonide transnasal nebulization group relative to the topical nasal steroids group.

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.