Geographic variation in allergic fungal rhinosinusitis

Impact of climate change on aerobiology, rhinitis, and allergen immunotherapy: Work Group Report from the Aerobiology, Rhinitis, Rhinosinusitis & Ocular Allergy, and Immunotherapy, Allergen Standardization & Allergy Diagnostics Committees of the American Academy of Allergy, Asthma & Immunology

Climate change is imposing a profound effect on health conditions triggered by environmental exposures. Climate change has affected aeroallergens in numerous ways, including: (1) changes in the vegetation microbiome distribution, (2) increases in C4 grasses globally, (3) increased occurrence of acute weather events, (4) increases in ambient temperature that amplify fungal spore concentration and pollen season duration, and (5) increased allergenicity of pollen and fungi due to exposure to higher levels of carbon dioxide, ozone, and diesel exhaust particles. In addition, greenhouse gases and air pollutants disrupt the epithelial barrier, trigger eosinophilic inflammation, and serve as adjuvants that stimulate IgE-mediated responses. All of these factors have influenced the prevalence and morbidity of allergic rhinitis, nonallergic rhinitis, and chronic rhinosinusitis. Data regarding changes in aeroallergen exposures due to climate change are lacking, and longitudinal sensitization data are rarely available. Allergists need to adapt diagnostic and treatment strategies to limit aeroallergen and air pollutant exposure and facilitate desensitization. Steps needed to address these challenges include: (1) expanding local measurement of pollen and fungal spores, (2) increasing the intensity of allergen avoidance measures, (3) addressing supply chain issues, and (4) promoting collaboration between allergists, insurance companies, aeroallergen manufacturers, and regulatory agencies.

Prostaglandin E Receptor 2 (EP2) Dysregulation in Allergic Fungal Rhinosinusitis Nasal Polyp Epithelium

OBJECTIVES

Allergic fungal rhinosinusitis (AFRS) is an eosinophilic subtype of chronic rhinosinusitis with nasal polyposis (CRSwNP). This study aimed to investigate the transcriptome of AFRS nasal polyp epithelium.

METHODS

Sinonasal epithelial cells were harvested from healthy nasal mucosa and polyp tissue collected from participants undergoing elective sinonasal surgery. Primary epithelial cells were subsequently grown in air/liquid interface and subjected to RNA-seq analysis, RT-qPCR, immunoblotting, and immunostaining.

RESULTS

A total of 19 genes were differentially expressed between healthy and AFRS sample epithelium. The second top candidate gene, ranked by adjusted p-value, was prostaglandin E receptor 2 (PTGER2). The upregulation of PTGER2 was confirmed by RT-qPCR and immunoblot. The presence of the EP2 receptor, encoded by the PTGER2 gene, was confirmed by immunocytochemistry.

CONCLUSION

PTGER2 is a potential novel therapeutic target for AFRS. EP2 dysregulation is associated with aspirin-exacerbated respiratory disease, potentially giving insight into common mechanisms of disease in severe CRSwNP.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:S1-S8, 2025.

Epidemiology of Orbital and Preseptal Cellulitis in the United States: A 13-Year Analysis

PURPOSE

To determine the incidence rates, risk factors, and economic burden of orbital and preseptal cellulitis in the United States (US).

METHODS

This retrospective longitudinal study was completed using data from the US Nationwide Emergency Department Sample dataset. An estimated 732,105 emergency department (ED) visits with a primary or secondary diagnosis of orbital and preseptal cellulitis from 2006 to 2018 were included. Incidence rates, descriptive statistics, and risk factors were calculated using linear and multivariate logistic regression models.

RESULTS

The incidence rates of preseptal cellulitis increased from 6.2 in 2006 to 19.2 per 100,000 US population in 2018. In contrast, orbital cellulitis incidence rates have been decreasing from 6.1 to 2.8 per 100,000 US population from 2006 to 2018, respectively. Young adults (ages 21-44) comprise a majority of patients with either preseptal or orbital cellulitis (31.7%; 95% CI, 30.5-33.0%). Hypertension (11.8%, 12.9%), tobacco use (11.2%, 9.6%), and sinusitis (9.2%, 4.3%) were the most commonly associated diagnoses for orbital and preseptal cellulitis, respectively. Only 27.6% of patients with orbital cellulitis were admitted with 64.7% of patients routinely discharged. The inflation-adjusted ED charges for patients with orbital and preseptal cellulitis from 2006 to 2018 totalled over $997 million.

CONCLUSION

Orbital and preseptal cellulitis are costly infections in the US with increasing incidence rates for preseptal cellulitis. High rates of routine discharge from the ED for orbital cellulitis may represent a knowledge gap amongst providers and an opportunity to improve care. Identifying individuals at risk for infection is key for diagnosis and appropriate triage of care.

V Brazilian Consensus on Rhinitis - 2024

Since we published the "IV Brazilian Consensus on Rhinitis", in2017, several advances have been achieved and have enabled a further understanding of the different aspects of "Rhinitis". This new guideline, developed jointly by ASBAI, SBP and SBORL, represents a relevant milestone in the updated and integrated management of the different forms of the disease, and it aims to unify evidence-based approaches to improve the diagnosis and treatment of this common and often underestimated condition. The document covers a wide range of topics, including clear definitions of the different phenotypes and endotypes of rhinitis, risk factors, updated diagnostic criteria, and recommended methods for clinical and laboratory investigation. We stress the importance of detailed clinical history and objective assessment, as well as tools for control and assessing severity tools an accurate diagnostic approach to the disease. Regarding treatment, it emphasizes the treatment customization, considering the severity of symptoms, the presence of comorbidities and the impact on the patient's quality of life. We discuss different drug treatment, in addition to non-pharmacological measures, such as environmental control and specific immunotherapy; and the possible role of immunobiological agents. Furthermore, the consensus addresses issues related to patient education, prevention and management of special situations, such as rhinitis in children, in pregnant women and in the elderly. In short, the "V Brazilian Consensus on Rhinitis" represents a comprehensive and updated guide for healthcare professionals involved in the diagnosis and management of rhinitis, aiming to improve patients' quality of life through an integrated and evidence-based approach.

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.

Characterising the allergic fungal rhinosinusitis microenvironment using full-length 16S rRNA gene amplicon sequencing and fungal ITS sequencing

INTRODUCTION

Allergic fungal rhinosinusitis (AFRS) is a severe phenotype of chronic rhinosinusitis with nasal polyposis (CRSwNP), characterised by localised and exaggerated type 2 inflammation. While fungal antigenic stimulation of unregulated Th2-mediated inflammation is the core pathophysiological mechanism, the direct and synergistic role of bacteria in disease modification is a pervasive hypothesis. We set out to define the microenvironment of AFRS to elucidate virulent organisms that may be implicated in the pathophysiology of AFRS.

METHODOLOGY

We undertook a cross-sectional study of AFRS patients and non-fungal CRSwNP patients. Demographics, disease severity, culture and microbiome sequences were analysed. Multimodality microbiome sequencing included short-read next-generation sequencing (NGS) on the Illumina Miseq (16S rRNA and ITS) and full-length 16S rRNA sequencing on the Oxford Nanopore Technologies GridION (ONT).

RESULTS

Thirty-two AFRS and 29 non-fungal CRSwNP patients (NF) were included in this study. Staphylococcus aureus was the dominant organism cultured and sequenced in both AFRS and NF groups (AFRS 27.54%; NF 18.04%; p = .07). Streptococcus pneumoniae (AFRS 12.31%; NF 0.98%; p = .03) and Haemophilus influenzae (AFRS 15.03%; NF 0.24%; p = .005) were significantly more abundant in AFRS. Bacterial diversity (Shannon's index) was considerably lower in AFRS relative to NF (AFRS 0.6; NF 1.0, p = .008). Aspergillus was the most cultured fungus in AFRS (10/32, 31.3%). The AFRS sequenced mycobiome was predominantly represented by Malassezia (43.6%), Curvularia (18.5%) and Aspergillus (16.8%), while the NF mycobiome was nearly exclusively Malassezia (84.2%) with an absence of Aspergillus or dematiaceous fungi.

CONCLUSION

A low diversity, dysbiotic microenvironment dominated by Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae characterised the bacterial microbiome of AFRS, with a mycobiome abundant in Malassezia, Aspergillus and Curvularia. While Staphylococcus aureus has been previously implicated in AFRS through enterotoxin superantigen potential, Streptococcus pneumoniae and Haemophilus influenzae are novel findings that may represent alternate cross-kingdom pathophysiological mechanisms.

The Relationship of Climate Change to Rhinitis

Evidence is mounting that climate change is having a significant impact on exacerbations of rhinitis. Concomitantly, the prevalence of allergic rhinitis is increasing at an accelerated rate. We herein explore the impact of carbon dioxide, barometric pressure and humidity changes, and anthropogenic pollutants on aeroallergens and rhinitis hypersensitivity. Important immune mechanisms underlying the climate-driven effects on rhinitis are discussed. Also, climate change is shifting ecological zones and seasons, increasing weather extremes, and altering regional atmospheric and environmental conditions. The direct impact of these factors on promoting allergic and nonallergic rhinitis is reviewed.

Histopathology of Allergic Fungal Rhinosinusitis Versus Chronic Rhinosinusitis with Nasal Polyps

OBJECTIVE

Structured histopathology (SHP) is a method of analyzing sinonasal tissue to characterize endotypes of chronic rhinosinusitis with nasal polyps (CRSwNP). Allergic fungal rhinosinusitis (AFRS) shares several features with certain endotypes of CRSwNP. Our objective was to compare the histopathology of AFRS and eosinophilic CRSwNP to further understand whether they are separate endotypes or disease entities altogether.

METHODS

A retrospective review of AFRS and CRSwNP patients undergoing endoscopic sinus surgery was performed. Data were collected on demographics, comorbidities, subjective and objective severity scores, and 13-variable SHP reports. CRSwNP patients with >10 eosinophils per high-power field (eCRSwNP) were included. Chi-squared and t-tests were used for statistical analysis.

RESULTS

A total of 29 AFRS and 108 eCRSwNP patients were identified. AFRS patients were younger and more often Black. Symptom severity scores (SNOT-22, Lund-MacKay, and Lund-Kennedy) were uniform between groups. AFRS patients had a higher rate of Charcot-Leyden crystals (41.4% vs. 10.2%; p < 0.001). Severe degree of inflammation, eosinophilic inflammatory predominance, eosinophil aggregates, subepithelial edema, and basement membrane thickening were common in both groups, and their rates were not statistically significantly different between groups. Metaplasia, ulceration, fibrosis, and hyperplastic/papillary change rates were low (<30%) and similar between groups.

CONCLUSION

The SHP of eCRSwNP and AFRS are highly consistent, which suggests AFRS is a severe subtype of CRSwNP overall rather than a separate disease entity. This also lends credence to AFRS belonging on the endotypic spectrum of CRSwNP.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2617-2621, 2024.

Manifestation and associated factors of systemic and local allergy among patients with allergic fungal rhinosinusitis: An observational study

Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis, characterized by excessive immune responses to environmental molds or fungi. The diagnosis and classification of AFRS into systemic and local types remain clinically challenging due to overlapping characteristics. This study investigated the prevalence of AFRS, its manifestation and associated factors in systemic and local AFRS. A total of 200 patients diagnosed with fungal rhinosinusitis underwent both skin provocation tests (SPT) and nasal provocation tests (NPT) to confirm AFRS and classify systemic and local types. Patients were considered to have AFRS if either the SPT or NPT was positive. Among these, patients with systemic AFRS were those who had a SPT positive. Local AFRS was when patients had a negative SPT and a positive NPT. Medical history, serum total IgE level, nasal endoscopy examinations, and CT scans were also recorded. Most patients were female (65.8%), with a mean age of 55.6 years (SD = 14.4). Based on the SPT and NPT results, 31% of patients (n = 62) were diagnosed with AFRS. Among these, 54.8% (n = 34) had systemic AFRS, while 45.2% (n = 28) had local AFRS. Patients with AFRS exhibited significantly higher levels of total IgE, eosinophils, and more pronounced signs and symptoms compared to those without AFRS. However, no statistically significant differences were observed between patients with systemic AFRS and those with local AFRS. AFRS was prevalent in our study. Among patients with AFRS, both systemic AFRS and local AFRS were also prevalent. While allergic indicators and clinical presentations can aid in AFRS diagnosis, minimal distinctions were observed between systemic and local AFRS. A comprehensive assessment incorporating both local and systemic allergic responses through provocation tests, such as a combination of skin and nasal tests, is imperative for optimizing AFRS diagnosis and management.

Update on the Role of Fungus in Allergy, Asthma, and the Unified Airway

The united airway refers to the combined upper and lower airways and their interconnected pathophysiologic relationships. Inflammatory airway diseases (chronic rhinosinusitis, asthma, and so forth) have been linked to fungal species through type 2 immune responses. These type 2 immune responses involve the cytokines interleukin (IL)-4, IL-5, IL-13, and a myriad of other inflammatory processes that lead to a spectrum of diseases from allergic bronchopulmonary mycosis to chronic rhinosinusitis. Historically, these diseases have been managed primarily with corticosteroids but recent revelations in the molecular pathophysiology provide opportunities for more diverse treatment options for patients with uncontrolled disease.

How Does Climate Change Affect the Upper Airway?

There is mounting evidence that climate change is having a significant influence on exacerbations of airway disease. We herein explore the physical factors of carbon dioxide, temperature increases, and humidity on intensifying allergen and fungal growth, and worsening air quality. The direct influence of these factors on promoting allergic rhinitis, chronic rhinosinusitis, and allergic fungal rhinosinusitis is reviewed.

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.

Allergic fungal rhinosinusitis: What we can learn from allergic bronchopulmonary mycosis

Allergic fungal rhinosinusitis (AFRS) and allergic bronchopulmonary mycosis (ABPM) are inflammatory disorders of the respiratory tract resulting from type 1 and 3 hypersensitivity reactions against fungi. The hallmark features of both diseases are eosinophil infiltration into the airway mucosa caused by localized type 2 inflammation and concomitant viscid secretions in the airways. Eosinophilic mucin-induced compression of adjacent anatomic structures leads to bone erosion and central bronchiectasis in the upper and lower respiratory tracts, respectively. Although these diseases share common features in their pathogenesis, they also exhibit notable differences. Epidemiologic findings are diverse, with AFRS typically presenting at a younger age, exhibiting less complicated bronchial asthma, and displaying lower total immunoglobulin E levels in laboratory findings compared with ABPM. Furthermore, despite their similar pathogenesis, the rarity of sinio-bronchial allergic mycosis in both AFRS and ABPM underscores the distinctions between these two diseases. This review aims to clarify the similarities and differences in the pathogenesis of AFRS and ABPM to determine what can be learned about AFRS from ABPM, where more is known.

Consideration of the Clinical Diagnosis of Allergic Fungal Sinusitis: A Single-Center Retrospective Study

INTRODUCTION

Allergic fungal rhinosinusitis (AFRS) is characterized by refractory and high recurrence rate. Improper treatment may lead to repeated recurrence and even serious complications, including vision loss, blindness, and intracranial complications. However, AFRS is easy to be misdiagnosed clinically.

OBJECTIVE

To ensure early diagnosis, the clinical presentations of patients with AFRS were studied.

METHODS

Data from patients with sinusitis hospitalized in the First Affiliated Hospital of the University of Science and Technology of China (USTC) from January 2015 to October 2022 were collected. The patients were divided into three groups; group A patients with AFRS, group B patients suspected of AFRS, and group C patients with fungus ball sinusitis (FBS).We retrospectively analyzed the data using IBM SPSS 19.0 to perform the chi-square test and one-way ANOVA test.

RESULTS

In total, 35 cases of AFRS, 91 cases of suspected AFRS, and 661 cases of FBS were rediagnosed. Compared with FBS patients, AFRS patients were younger, the total IgE, the percentage of eosinophils and basophils in peripheral blood were higher, and the proportion of patients with allergic rhinitis, asthma or hypo olfactory was higher. It had a higher recurrence rate. These results were also observed in the comparison between suspected AFRS patients and FBS patients, but no significant difference was found in the comparison between suspected AFRS patients and suspected AFRS patients.

CONCLUSIONS AND SIGNIFICANCE

AFRS may be misdiagnosed due to the low detection of fungi. To ensure early diagnosis, we recommend that patients with clinical, radiological, and laboratory features similar to those of AFRS but without evidence of fungal staining be treated according to the treatment criteria of AFRS.

New Developments in Allergic Fungal Rhinosinusitis Pathophysiology and Treatment

BACKGROUND

Allergic fungal rhinosinusitis (AFRS) is an endotype of chronic rhinosinusitis (CRS) with nasal polyps characterized by eosinophilic mucin laden with fungal hyphae entrapped in expanded sinus cavities with an exaggerated hypersensitivity to fungal elements. The last decade has elucidated fungi-driven inflammatory pathways contributing to the pathophysiology of chronic inflammatory respiratory diseases. In addition, novel therapeutic biologic options have become available for CRS over the last several years.

OBJECTIVE

To review the current literature examining AFRS, focusing on recent developments in our understanding of its pathophysiology and implications for treatment options.

METHODS

Review article.

RESULTS

Fungi-driven respiratory inflammation has been linked to fungal proteinases and toxin activity. In addition, AFRS patients demonstrate a local sinonasal immunodeficiency in antimicrobial peptides and hence limited antifungal activity, along with an exaggerated type 2 inflammatory response, highlighting a possible imbalanced type 1, type 2, and type 3 profile. The elucidation of these dysregulated molecular pathways has highlighted novel potential therapeutic targets. As such, the clinical management of AFRS, which once included surgery and extended courses of oral corticosteroids, is transitioning away from long courses of oral corticosteroids to incorporate novel delivery mechanisms of topical therapeutic targets and biologics for recalcitrant disease.

CONCLUSION

AFRS is an endotype of CRS with nasal polyps (CRSwNP) for which the molecular pathways leading to its inflammatory dysfunction are beginning to be illuminated. In addition to affecting treatment options, these understandings may shape necessary changes to diagnostic criteria and the extrapolated effects of environmental changes on AFRS. More critically, a better appreciation of fungi-driven inflammatory pathways may have implications for the understanding of broader CRS inflammation.

A Clinico-Pathological Study of Allergic Fungal Rhinosinusitis at a Tertiary Care Center of Western Rajasthan

Allergic fungal rhinosinusitis (AFRS) is a non-invasive fungal sinusitis resulting from an immunologic response to the presence of extra mucosal fungal hyphae in the sinuses. Here we studied clinicopathological characteristics of AFRS among patients of chronic rhinosinusitis with nasal polyposis who underwent Functional Endoscopic Sinus Surgery (FESS) at a tertiary care in western Rajasthan. Standard ethical protocol was followed for the present study. We did a prospective study on admitted patients of chronic rhinosinusitis with nasal polyposis in the department of Otorhinolaryngology and Head & neck surgery, Dr. S. N. Medical College, Jodhpur from January 2018 to August 2019, who underwent FESS. The patient's history, clinical and endoscopic findings with radiological features were recorded. Biopsy specimens were sent for fungal staining, culture, and histopathology. As per Bent and Kuhn criteria, 25 cases out of 100 were diagnosed as AFRS, mean age was 27.46 ± 13.36. Nasal obstruction and nasal discharge were the most common symptoms. On histopathological examination fungal hyphae found in 18 cases (72%), allergic mucin in 25 cases (100%) and eosinophilic infiltrate in 20 cases (80%). Fungal culture positive in 15 cases (60%) of AFRS. In which aspergillus flavus present in 12 (80%). Allergic fungal rhinosinusitis should be considered as an important differential diagnosis in patients with chronic rhinosinusitis with nasal polyposis and for this surgery should be the treatment of choice.

Allergic Fungal Rhinosinusitis: The Role and Expectations of Biologics

Allergic fungal rhinosinusitis (AFRS) is a noninvasive subtype of chronic rhinosinusitis with nasal polyps (CRSwNP) that usually develops in immunocompetent atopic individuals and is more common in geographic regions characterized by warm temperatures and high humidity, conducive to higher environmental fungal presence. Allergic fungal rhinosinusitis usually presents with unique computed tomography findings and significant polyp burden, yet patients often report minimal sinus symptoms. Patients with AFRS often have extremely elevated serum total and fungal-specific IgE levels. Treatment almost always requires surgery, in which adjuvant medical therapy is critical to success. However, until recently the choice of adjuvant therapy has consisted primarily of either oral and/or topical steroids. Although oral corticosteroids decrease recurrence after surgery, data for the effectiveness of other adjunctive pharmacologic agents, including topical and oral antifungal agents and immunotherapy, have remained unclear and hence are not recommended in recent guidelines including the International Consensus of Allergy and Rhinology. Three biologics, omalizumab, dupilumab, and mepolizumab, have recently been approved for treating CRSwNP in general, but clinical trials to date with these biologics did not involve AFRS patients. Recently published case reports and smaller prospective studies have shown good efficacy of these biologics on the AFRS subgroup of patients. This article provides an overview of the understanding of the pathophysiology of AFRS, implications of this understanding on the possible role of biologics, and clinical reports on the use of biologics in treating AFRS. Because biologics are indicated for treating CRSwNP, follow up real-world evidence studies are needed for AFRS.

Allergic fungal rhinosinusitis presented as a unilateral nasal mass: A first case report from Thailand and literature review

Background

Allergic fungal rhinosinusitis (AFRS) is a relatively new inflammatory sinonasal disease. Prevalence of the disease is reported to be highly different across Asia.

Case presentation

A 23-year-old Thai male came to our hospital with left-sided nasal obstruction. Endoscopic examination found a mass originated from the left sphenoethmoidal recess. Incisional biopsy result of the mass indicated an inflammatory process and high level of serum specific IgE to several aeroallergens was found. Based on the biopsy results and other investigations, the diagnosis of AFRS was made and the patient was treated successfully with endoscopic sinus surgery and postoperative systemic/topical steroids.

Discussion

While AFRS is quite common in some regions, the disease is rarely encountered in Thailand and can be presented as a unilateral lesion, mimicking a tumor mass, which could lead to an incorrect diagnosis and inappropriate treatment.

Conclusion

Even though AFRS is rarely reported in our country, it still can be found and might be recognized falsely as a neoplastic process. High level of awareness of the disease features could help to minimize inappropriate disease management.

The Impact of Climatic, Socioeconomic, and Geographic Factors on the Prevalence of Allergic Fungal Rhinosinusitis: A Worldwide Ecological Study

BACKGROUND

The prevalence of allergic fungal rhinosinusitis (AFRS) and its associated risk factors have been an issue of debate. Some epidemiological factors have been correlated to the disease prevalence.

OBJECTIVES

To observe the prevalence pattern of AFRS worldwide and to investigate the effect of specific epidemiological factors on the disease prevalence.

METHODS

A systematic review was derived from 1983 to December 2018. Data on the prevalence of AFRS were collected from the selected studies. Relevant factors assessing each city's climate, socioeconomics and geography were used to study the association with AFRS prevalence.

RESULTS

35 cities across 5 continents were investigated. The worldwide average rate of AFRS in CRS cases is 7.8% (0.2%-26.7%) in which more than half of the investigated cities (57%) had low AFRS prevalence, while the remaining cities had intermediate (11%) and high (32%) prevalence. Cities with higher temperatures were associated with a higher prevalence of AFRS (p-value 0.002), whereas cities with humid continental climate were significantly associated with a low prevalence of AFRS (p-value 0.032). Humidity and wind speed were lower in the cities with higher AFRS prevalence (p-value 0.018 and 0.008, respectively). There were no significant correlations between AFRS prevalence and economic levels, presence of water bodies, rainfall amounts, altitude, and presence of forests.

CONCLUSION

AFRS has a worldwide distribution pattern with varying prevalence. In this ecological study, we observed a correlation between AFRS prevalence and climatic factors (climate classification, humidity, temperature, and wind speed). Socioeconomic factors should be analyzed on an individual basis for better assessment of the relationship with disease prevalence.

Precision Medicine in Chronic Rhinosinusitis: Where Does Allergy Fit In?

Chronic rhinosinusitis (CRS) is a clinical syndrome stemming from persistent inflammation of the sinonasal mucosa. Phenotypically, it is traditionally and widely described according to the presence or absence of polyps. While this distinction is simple to use, it has little bearing on prognosis and treatment, for CRS is essentially an inflammatory disease resulting from dysregulated interaction between a multitude of host and environmental factors. Allergy is merely one of them and, like many of the proposed aetiologies, has been subject to much debate which will be discussed here. As our understanding of CRS continues to evolve, previous so-called conventional wisdom about phenotypes (e.g. CRS with nasal polyps is associated with Type 2 inflammation) is being challenged, and new phenotypes are also emerging. In addition, there is growing interest in defining the endotypes of CRS to deliver precise and personalised treatment, especially pertaining to the development of biologics for the group of severe, difficult-to-treat CRS patients. A proposed model of precision medicine tailored to management of CRS will also be introduced to readers, which can be continually modified to adapt to new discoveries about this exciting condition.

Chronic Rhinosinusitis Disease Disparity in the South Florida Hispanic Population

OBJECTIVES/HYPOTHESIS

The role of social determinants of health in chronic rhinosinusitis (CRS) is poorly characterized. Limited research examining CRS health disparities indicates that minority status is associated with worse CRS. However, many of these studies are retrospective or performed in populations without substantial ethnic minorities. Rhinologists need to characterize existing CRS disease disparities to develop targeted strategies for improving care in these populations. This prospective study assesses preoperative CRS disease burden in South Florida (SFL) Hispanic and non-Hispanic patients and examines potential factors contributing CRS disease disparities.

STUDY DESIGN

Prospective cohort study.

METHODS

The prospective cohort study included consecutive patients having primary endoscopic sinus surgery (ESS) for CRS between September 2019 and February 2020 with complete preoperative data. Data were collected in clinic and surgery. Descriptive statistics compare Hispanic and non-Hispanic cohorts. Linear regression adjusts for confounders. Relative risk (RR) compared CRS severity markers.

RESULTS

Thirty-eight Hispanic and 56 non-Hispanic patients met inclusion criteria. Age, sex, CT scores, insurance payer, and comorbidities were similar between cohorts. Hispanics presented with worse 22-item Sinonasal Outcome Test (SNOT-22) (55; SD = 18) compared to non-Hispanics (37; SD = 22) (P < .001). Hispanics tended to have a higher risk of severe CRS markers, including nasal polyps RR = 2.5 (95% CI: 1.0-5.9), neo-osteogenesis RR = 1.6 (95% CI: 0.5-4.7), extended procedures (i.e., draft III) RR = 2.97 (95% CI: 1.0-9.1), and tissue eosinophilia RR = 1.46 (95% CI: 0.6-3.5). Hispanics reported longer sinonasal symptom duration.

CONCLUSIONS

SFL hispanic patients presenting for primary ESS have worse sinonasal disease burden. SFL Hispanics have markers of greater CRS severity and report longer delays before receiving CRS care. These factors may contribute to increased sinonasal disease burden in Hispanic patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:2659-2665, 2021.

Demographic Variation in Chronic Rhinosinusitis by Subtype and Region: A Systematic Review

BACKGROUND

Chronic rhinosinusitis (CRS) describes a heterogenous group of diseases including CRS with (CRSwNP) or without nasal polyps (CRSsNP), aspirin-exacerbated respiratory disease (AERD), and allergic fungal rhinosinusitis (AFRS). It affects 10 to 15% of the US population and is more common in women and White patients. However, these estimates are based on survey and database studies with innate diagnostic inaccuracy. Additionally, few studies report subtype-specific demographics. We explore the demographic differences of CRS in the U.S. by subtype and region.

OBJECTIVE

To characterize demographic differences between the CRS population and the overall US population, and also between different CRS subtype populations.

METHODS

We performed a systematic review for articles reporting on US demographics of adults with CRS. Study participants were required to have been diagnosed using consensus criteria. Data on demographics, geographic region, and CRS subtype were analyzed.

RESULTS

Our study analyzed 31 unique studies representing 8409 patients with 50.7% females and weighted mean age of 48.0 years. Compared to the overall US population, CRS patients were predominantly White (78.5%) and non-Hispanic (94.5%) with under-representation of other races. Grouped by subtype, CRSwNP affected a significantly higher proportion of men (59.8%). AFRS affected a significantly higher proportion of Black patients (53.8%) while CRSsNP was more prevalent in White patients (84.2%). When grouped by region, the South had a significantly higher proportion of female (53%) and Black (17.8%) CRS patients. The West had a significantly higher proportion of Asian (4.5%) and Hispanic (12.3%) patients.

CONCLUSIONS

Significant demographic differences exist in CRS patients based on subtype and region. These data provide an estimation of the demographic make-up of CRS, but further high-level demographic studies are needed.

Prevalence of Aspergillus fumigatus skin positivity in adults without an apparent/known atopic disease in Uganda

Background:

Skin prick testing (SPT) is an important investigation in the evaluation of allergy to fungal pathogens. However, the background sensitivity to fungal allergens among healthy people in Uganda is unknown. Our aim was to assess the background prevalence of Aspergillus fumigatus SPT positivity in apparently healthy adults without known atopic disease in Uganda.

Methods:

For this pilot study, we recruited 50 healthy volunteers using convenience sampling, 56% of whom were health workers. We performed the SPT for A. fumigatus according to manufacturer’s instructions. A wheal diameter of ⩾3 mm was considered positive.

Results:

The prevalence of A. fumigatus skin positivity was 60% (30/50). Participants with a positive A. fumigatus SPT were significantly younger than those with a negative result [median age (years): 28 versus 35; p = 0.005].

Conclusion:

There is a high skin positivity against A. fumigatus among non-atopic healthy Ugandan adults. There is an urgent need to establish a normal wheal cut-off value for this population. SPT alone may be an unreliable test for the diagnosis of A. fumigatus associated allergic syndromes. More studies are needed to define the prevalence of A. fumigatus skin positivity among non-atopic healthy population in Africa.

Pediatric Allergic Fungal Sinusitis: A Clinical Review

Allergic fungal sinusitis (AFS) is the most common type of fungal sinus infection. AFS is a robust allergic reaction to inhaled soil fungi that causes sinus inflammation, and the fungal debris then accumulates in the sinus cavities. This accumulation can cause nasal polyps, facial pain and pressure, bone remodeling of the face, and even bone erosion, which can cause damage to the eyes and brain. AFS can also cause thick, sticky nasal mucus and postnasal drip, and it can affect the sense of smell. Most patients with AFS are adolescents who also have chronic symptoms of allergic rhinitis and asthma. Endoscopic sinus surgery to remove the disease and open the sinus cavities is the main treatment approach. Adjuvant immunotherapy is helpful in reducing the inflammatory response and preventing future recurrence of this allergy-mediated condition. [Pediatr Ann. 2021;50(7):e297-e303.].

An overview of possible pathogenesis mechanisms of Alternaria alternata in chronic rhinosinusitis and nasal polyposis

Chronic Rhinosinusitis (CRS) is a multifactorial disease, and different etiologies like metabolism and immunity disorders, bacterial superantigens, biofilms, and fungal allergens are known to develop this disease, especially the CRS with nasal polyps. Alternaria alternata (Alternaria) is one of the most prevalent airborne fungal species in the nasal discharge, which might have vigorous immunologic activities in nasal epithelial cells and play an essential role in the pathogenesis of CRS. Moreover, the interaction between this fungus and the innate and adaptive immune systems leads to the development of chronic inflammation. This inflammation may consequently instigate the CRS and nasal polyposis. The attenuation of surfactant protein synthesis or intracellular reserves and mucus hypersecretion could prevent the clearance of Alternaria from sinuses and may be correlated with colonization and re-infection of airborne fungi. Furthermore, higher expression of cathelicidin, thymic stromal lymphopoietin, toll-like receptors, and T helper 2-dominant immune responses can result in an IgE-mediated pathway activation and eosinophils degranulation. Moreover, higher local Alternaria-specific IgE was shown to be correlated with eosinophilic cationic proteins and might relate to nasal polyps. However, the role of genetic and environmental factors affecting CRS and nasal polyposis is not well studied. Likewise, further animal and clinical studies are required to better understand the role of Alternaria in CRS disease. The current article reviews the recent findings around the Alternaria-induced CRS and nasal polyposis.

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.

The burden of serious fungal infections in Azerbaijan

BACKGROUND

Azerbaijan is an upper middle-income country in South Caucasus with an area of 86,600 km2 and a total population of 10 million people and gross domestic product of US $4480 per capita. The aim of this research is to estimate fungal infection burden and highlight the problem at national and international levels.

METHODS

Fungal infection burden was estimated using data from epidemiological papers and population at risk and LIFE (Leading International Fungal Education) modelling.

RESULTS

The number of people living with human immunodeficiency virus (PLHIV) in 2018 was 6193, 29% of them not receiving antiretroviral therapy. Based on 90% and 20% rates of oral and oesophageal candidiasis in patients with CD4 cell count <200 µl-1 we estimate 808 and 579 patients with oral and oesophageal candidiasis, respectively. The annual incidences of cryptococcal meningitis and Pneumocystis pneumonia are 5 and 55 cases, respectively. We estimated 2307 cases of chronic pulmonary aspergillosis (CPA), 4927 patients with allergic bronchopulmonary aspergillosis (ABPA), and 6504 with severe asthma with fungal sensitization (SAFS). Using data on chronic obstructive pulmonary diseases (COPD), lung cancer, acute myeloid leukaemia rates, and number of transplantations, we estimated 693 cases of invasive aspergillosis following these conditions. Using a low-European rate for invasive candidiasis, we estimated 499 and 75 patients with candidemia and intra-abdominal candidiasis respectively. The number of adult women (15-55 years) in Azerbaijan is ~2,658,000, so it was estimated that 159,490 women suffer from recurrent vulvovaginal candidiasis (rVVC).

DISCUSSION

In total, the estimated number of people suffering from fungal diseases in Azerbaijan is 225,974 (2.3% of the population). However, the fungal rate is underestimated due to lack of epidemiological data. The most imminent need is improvement in diagnostic capabilities. This aim should be achieved via establishing a reference laboratory and equipping major clinical centers with essential diagnostics assays.

The Role of Home Fungal Exposure in Allergic Fungal Rhinosinusitis

BACKGROUND

Allergic fungal rhinosinusitis (AFRS) is disproportionately identified in patients of low socioeconomic status living in warm, humid climates, and is thought to occur in response to environmental fungal species.

OBJECTIVE

We hypothesized that micro-geographic differences in fungal exposure contribute to the pathogenesis of AFRS, and compared home fungal exposure of patients with AFRS to normative data and controls.

METHODS

Comprehensive prospective enrollment and data capture was completed in 70 patients. Patients with AFRS were compared to a control population with chronic rhinosinusitis with nasal polyposis (CRSwNP) and comorbid atopy. Comprehensive demographics, 22-item sino-nasal outcomes test (SNOT-22) questionnaires, and endoscopy scores were compiled. Using a test strip collection system, a home fungal assessment was completed for each patient, along with detailed questions related to home condition.

RESULTS

Patients with AFRS were more likely to be younger (p<.001), African American (p<.001), from a lower income bracket (p < .012), and less likely to own their home (p < .001). There were no differences in prior surgeries (p=.432), endoscopy scores (p = .409) or SNOT-22 scores (p = .110) between the groups. There were no differences in overall fungal counts between patients with AFRS and controls (p = .981). AFRS patients had a higher prevalence of Basidiospores than controls (p = .034).

CONCLUSION

This study failed to detect differences in total home fungal exposure levels between those with AFRS and atopic CRSwNP, despite differences in socioeconomic status. This suggests that absolute fungal levels may not be the primary driver in development of AFRS, or that the fungal detection strategies utilized were not representative of patients' overall fungal exposure.

Biologics in chronic rhinosinusitis with nasal polyposis

OBJECTIVE

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common and heterogeneous inflammatory condition, for which the drivers of the underlying inflammation are not yet fully understood. The use of biologic therapies to target specifically relevant effector cells or cytokines in CRSwNP is a growing field of interest. The objectives of this review are to provide an update on the existing studies of biologics in CRSwNP and to identify potential future areas for further research.

DATA SOURCES

An initial literature review of biologic therapies in CRS was performed through publications gathered from a PubMed search for title/abstract containing "biologic" and "chronic rhinosinusitis." Further manuscripts describing scientific premise for each biologic were then reviewed.

STUDY SELECTIONS

A detailed review of all studies describing biologic therapies targeting inflammation in CRSwNP was performed.

RESULTS

Biologic therapies targeting interleukin (IL)-4Rα, IL-5, IL-5Rα, IL-33, immunoglobulin (Ig)E, and thymic stromal lymphopoietin (TSLP) have all been developed and have been investigated for treatment in CRSwNP, or current research suggests that they may have utility in this area. Only dupilumab, which inhibits IL-4Rα, has gained Food and Drug Administration approval for the treatment of adults with inadequately controlled CRSwNP.

CONCLUSION

Recent advances in our understanding of the fundamental drivers of the chronic respiratory inflammation in CRSwNP has led to the identification of several potential therapeutic targets for this disease. Future clinical success will rely on the availability of biomarker-based endotyping and responder analyses so that clinicians can precisely match each patient to the appropriate biologic, thereby optimizing the proper treatment strategy.

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.

Two Cases of Allergic Fungal Sinusitis with Differing Postoperative Course

Allergic fungal sinusitis (AFS) often develops in unilateral paranasal sinuses, which must be differentiated from tumors. When AFS develops on both sides, however, it must be differentiated from eosinophilic chronic sinusitis with evident eosinophilic infiltration at nasal/paranasal sinus mucosa; both conditions are highly recurrent and commonly considered intractable paranasal sinusitis. Surgical correction is the primary treatment method for AFS, as it is essential to connect the paranasal sinus communication to ensure exhaustive resection of the pathologic mucosa and for nasal steroids to reach each paranasal sinus. We recently encountered two AFS cases with differing postoperative courses. Case 1 showed evident exacerbation in the computed tomography findings, which suggests progression to eosinophilic sinusitis. Case 2 showed a benign prognosis without recurrence. Close long-term follow-up should be mandatory after surgery for the treatment of AFS.

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.

Allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is a subset of chronic rhinosinusitis with nasal polyps (CRSwNP) characterized by antifungal IgE sensitivity, eosinophil-rich mucus (ie, allergic mucin), and characteristic computed tomographic and magnetic resonance imaging findings in paranasal sinuses. AFRS develops in immunocompetent patients, with occurrence influenced by climate, geography, and several identified host factors. Molecular pathways and immune responses driving AFRS are still being delineated, but prominent adaptive and more recently recognized innate type 2 immune responses are important, many similar to those established in patients with other forms of CRSwNP. It is unclear whether AFRS represents merely a more extreme expression of pathways important in patients with CRSwNP or whether there are other disordered immune responses that would define a distinct endotype or endotypes. Although AFRS and allergic bronchopulmonary aspergillosis share some analogous immune mechanisms, the 2 conditions do not occur commonly in the same patient. Treatment of AFRS almost always requires surgical debridement of the involved sinuses. Oral corticosteroids decrease recurrence after surgery, but other adjunctive pharmacologic agents, including topical and oral antifungal agents, do not have a firm evidence basis for use. There is good rationale for use of biologic agents that target eosinophilic inflammation or other type 2 responses, but studies in patients with AFRS are required.

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.

Estimated burden of serious human fungal diseases in Turkey

The current number of fungal infections occurring each year in Turkey is unknown. We estimated the burden of serious human fungal diseases based on the population at risk, existing epidemiological data from 1920 to 2017 and modelling previously described by the LIFE program (http://www.LIFE-worldwide.org). Among the population of Turkey (80.8 million in 2017), approximately 1 785 811 (2.21%) people are estimated to suffer from a serious fungal infection each year. The model used predicts high prevalences of allergic fungal rhinosinusitis episodes (312 994 cases) (392/100 000), of severe asthma with fungal sensitisation (42 989 cases) (53.20 cases/100 000 adults per year), of allergic bronchopulmonary aspergillosis (32 594 cases) (40.33/100 000), of fungal keratitis (26 671 cases) (33/100 000) and of chronic pulmonary aspergillosis (5890 cases) (7.29/100 000). The estimated annual incidence for invasive aspergillosis is lower (3911 cases) (4.84/100 000 annually). Among about 22.5 million women aged 15-50 years, recurrent vulvovaginal candidiasis is estimated to occur in 1 350 371 (3342/100 000) females. The burden of three superficial fungal infections was also estimated: tinea pedis (1.79 million), tinea capitis (43 900) and onychomycosis (1.73 million). Given that the modelling estimates reported in the current study might be substantially under- or overestimated, formal epidemiological and comprehensive surveillance studies are required to validate or modify these estimates.

Rhinological observations during a humanitarian mission in a rural sub-Saharan African setting

AIMS

Patients with rhinological symptoms and pathologies represent an important population. Their prevalence in developing areas without ENT care is not well documented. Due to various factors like migration, they may have an influence out of these territories. Our objective was to determine the prevalence and epidemiology of the main rhinological symptoms and pathologies during a humanitarian mission.

MATERIAL AND METHODS

Six hundred and seventy nine patients presenting to our general medical consultations were examined. All of them had careful interrogation and a basic ENT check-up. Patient data and correlating photos were registered to be analyzed retrospectively.

RESULTS

The ethnic origins of the patients were different. Most of them were younger than 50 years old. The rhinological problems were amongst the most frequent reasons to consult, the prevalence was higher when secondary findings and complaints were also considered, representing altogether 44 (6.48%) cases.

CONCLUSION

A high prevalence of rhinological pathologies showing the importance of public health issues, screening and an important need of adapted treatments was found. Due to migration, climatic changes and humanitarian missions, their presentation and incidence may vary. Health care providers and rhinologists need a thorough knowledge of community acquired and tropical pathologies.

Ethnic and Gender Differences in Bone Erosion in Allergic Fungal Sinusitis

Background

Erosion of the bony sinus walls in allergic fungal sinusitis (AFS) is an established phenomenon. Reports of the incidence of bone erosion in AFS vary widely, and definitions of bone erosion lack uniformity. Differences in bone erosion among ethnic and gender groups have not been examined previously in the literature.

Methods

At our institution we reviewed 47 cases of AFS for ethnic and gender differences in presentation and presence of bone erosion.

Results

Caucasians presented at a mean 12 years later than African-Americans (p = 0.002); however, this difference was largely carried by Caucasian females. African-Americans presented with a greater incidence of bone erosion than Caucasians (p = 0.028). In addition, there are statistically significant differences in the individual paranasal sinuses affected by bone erosion in AFS.

Conclusions

We examine the potential implications of ethnic and gender differences in presentation and bone erosion in AFS.

Prevalence of Noninvasive Fungal Sinusitis in South Australia

Background

The aim of this study was to document the prevalence of noninvasive fungal sinusitis in patients with chronic sinusitis and thick viscous secretions in South Australia.

Methods

We studied of 349 patients with chronic rhinosinusitis undergoing endoscopic sinus surgery in a specialized rhinology practice. Patients with nasal polyposis and thick fungal-like sinus mucin had operative samples sent for microscopy and fungal culture. Evidence of atopy was taken as positive radioallergosorbent or skin-prick tests to fungi.

Results

One hundred and thirty-four (38%) patients were noted to have thick, viscid sinus mucin, raising suspicion of fungal disease. Ninety-three patients had positive fungal cultures or microscopy (26.6%). It was possible to classify 95.5% of the patients into subgroups of noninvasive fungal sinusitis or nonfungal sinusitis: 8.6% of patients with allergic fungal sinusitis, 1.7% of patients with allergic fungal sinusitis–like sinusitis, 15.2% of patients with chronic fungal sinusitis, one patient with a fungal ball, and the remaining 69% of patients with nonfungal chronic sinusitis.

Conclusion

This is the first prospective study to evaluate the prevalence of these increasingly widely recognized conditions. It highlights the need for otolaryngologists to be alert to these not uncommon diagnoses in order for early, appropriate medical and surgical management to be instituted.

Social Factors in the Development of Chronic Rhinosinusitis: a Systematic Review

PURPOSE OF REVIEW

In an era where prevention is paramount, understanding social factors for chronic rhinosinusitis (CRS) may facilitate preventive interventions that mitigate risk factors associated with the initiation or progression of the disease.

RECENT FINDINGS

Both passive and active smoking are clearly and unequivocally associated with both the incidence and the severity of rhinosinusitis, while there an increasing body of evidence linking social deprivation and low socioeconomic status with rhinosinusitis and its complications. However, overall, only a handful of studies were longitudinal, while the available studies suffer from lack of standardized definitions of rhinosinusitis. In this systematic review, we assessed the available evidence linking CRS with social factors, such as socioeconomic status and class, educational status, family status, living and working location and conditions, and use of toxins or recreational drugs as well as exercise and diet. Thirty studies from 1995 onwards fulfilled our inclusion criteria and were used for this review. Social deprivation and low socioeconomic level seem to be directly associated with rhinosinusitis, as there are pollutants in living or working environment. A clear and direct association between smoking (both active and passive) and rhinosinusitis was also shown. However, the link between rhinosinusitis and education level, and exercise and diet, if any, seems to be more complex.

Patient and surgeon factors explain variation in the frequency of frontal sinus surgery

OBJECTIVES/HYPOTHESIS

Ethmoidectomy may be sufficient to address frontal sinus disease, but some surgeons may perform frontal recess dissection initially. Our objectives were to describe patient-associated factors with frequency of frontal sinus surgery and analyze the association with provider volume.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

The 2013 State Ambulatory Surgery Databases of New Jersey, Florida, and Kentucky were queried to identify adults who underwent anterior ethmoidectomy or total ethmoidectomy using standard Current Procedural Terminology codes. Univariate and multivariate logistic regression was performed to determine the odds of undergoing concurrent frontal sinus exploration along with ethmoidectomy, adjusting for age, gender, race, insurance type, median income, and the metropolitan designation by zip code. We also examined provider and center volume, use of image guidance, and total charges.

RESULTS

There were 10,564 ethmoidectomies, of which 4,726 had concurrent frontal sinus surgery. Women were less likely to have frontal sinus surgery (P = .0011), as were patients with Medicare (P = .007). Hispanics were more likely to have frontal sinus surgery (P = .0003). Surgeons with higher surgical volumes were more likely to perform frontal sinus surgery; it was also more likely to be performed in centers where more sinus procedures occurred (P < .0001, both).

CONCLUSIONS

Variation in the utilization of frontal sinus surgery is associated with patient sex, ethnicity, insurance status, geography, as well as provider and hospital volumes. These data support the idea that nonclinical factors may influence the treatment of frontal sinus disease.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:2008-2014, 2018.

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.

Etiology of Chronic Rhinosinusitis: The Role of Fungus

Chronic rhinosinusitis (CRS) is a multifactorial disease. Predisposing factors can be divided into environmental and non-host factors, such as pollution, viral infections, smoking, fungus, and bacteria; general host factors, including genetic factors and immune deficiency; and local host factors, including persistent focal inflammation within the ostiomeatal complex. Evidence suggests that the underlying bone in the ostiomeatal complex is actively involved in the disease process of CRS. The evidence concerning a broad range of predisposing factors for CRS is reviewed. Chronic rhinosinusitis is an inflammatory disorder with numerous predisposing factors, including genetics, pollution, anatomic anomalies, bacteria, and fungus. In some studies, fungi have been cultured from nearly 100% of patients with rhinosinusitis and nasal polyposis. T-cell sensitization to fungus with production of the T-helper 2 (Th2) cytokine interleukin-5 has been proposed as a key step in the initiation of the disease. Interleukin-5 also plays an important role in the effector phase of the disease through its effects on eosinophilopoesis and eosinophil survival. There is considerable controversy concerning the role of fungi as the cause of “chronic eosinophilic rhinosinusitis” and whether this even represents a distinct clinical entity. Further study is also required to define the optimal treatment for the disease.