Orbital involvement in allergic fungal sinusitis

Allergic Fungal Sinusitis: Ophthalmic Complications Due to the COVID-19 Pandemic and the Potential of Telemedicine

We report a case of a 26-year-old female who initially presented to an outside optometrist with complaints of proptosis and decreased visual acuity. Magnetic resonance imaging (MRI) obtained at that time was concerning for allergic fungal sinusitis. Unfortunately, the patient’s referral to ophthalmology was delayed due to the coronavirus disease 2019 (COVID-19) pandemic. On presentation to ophthalmology one year later, the patient had clinically deteriorated with significant visual and olfactory loss. She underwent emergent endoscopic sinus surgery by otolaryngology with histological analysis of the sinus debris confirming allergic fungal sinusitis. This is a unique case demonstrating the devastating impact that the COVID-19 pandemic had on patient care for an otherwise treatable condition. We propose the utilization of telemedicine networks as a way to prevent similar complications.

Orbital mycoses in an adult subtropical population

Background/objectives

To report the spectrum of fungal infections involving the orbit encountered in an Australian subtropical population with respect to presentation, host risk factors, involved pathogens, treatment and outcomes.

Subjects/methods

A retrospective chart review was performed on all adult patients with orbital mycosis treated by the senior author (TJS) from 1986 to 2017 in a tertiary setting.

Results

Thirty cases of fungal infection involving the orbit were included in this case series. Of these, 26 patients had invasive disease and four patients had non-invasive disease. Causative organisms included mucormycosis (16), aspergillus (8) and other fungi (7). Common risk factors included haematological disorders or malignancy, neutropenia, corticosteroid use and diabetes mellitus. Mucormycosis in three immunocompetent patients was caused by Apophysomyces elegans. Orbital apex syndrome was observed in approximately one third of patients at initial ophthalmological assessment. Amphotericin B was used in most cases of mucormycosis, while there was a more varied spectrum of anti-fungal use in other fungal infections. Seven patients with mucormycosis proceeded to orbital exenteration with a survival rate of 43%. No patients with other orbital fungal infections were exenterated.

Conclusions

Orbital mycoses are not only opportunistic but true pathogenic infections. While initial symptoms may be varied, the development of orbital apex syndrome should raise suspicion for this condition, regardless of patient immune status or age. Survival and visual outcomes are often poor with invasive disease. Multidisciplinary team management with early orbital specialist involvement is essential.

Ophthalmic Manifestations of Allergic Fungal Sinusitis

PURPOSES

To study the ophthalmic manifestations of patients with allergic fungal sinusitis (AFS) and evaluate the importance of early diagnosis and management in preventing the possible future complications of AFS.

METHODS

Retrospective chart review of 100 patients with the diagnosis of AFS from a single institution was performed. Age, gender, clinical presentation including ophthalmic and radiological findings, immune status, patterns of sinus involvement, medical and surgical intervention needed, laboratory results, and the course of the disease were evaluated.

RESULTS

The mean age at presentation was 19.8 years (range, 10-42 years) with no clear gender predominance (52% of patients were female).The most common sinuses involved were ethmoid and maxillary sinuses. All patients underwent functional endoscopic sinus surgery and received systemic and topical steroids. There were no intervention-related complications. Thirty-four of 100 patients had ophthalmic consequences of AFS. The most common ophthalmic presentation was proptosis (n = 21, 61.7%), followed by epiphora (n = 5, 14.7%), visual loss (n = 4, 11.7%), diplopia (n = 3, 8.8%), and dystopia (n = 1, 2.9%) in addition to 1 patient having ptosis beside proptosis. CT scans of these 34 patients showed that 82.3% had nonhomogenous opacification of sinuses, 52% had erosion of lamina papyracea, 17.6% had intraorbital extension, and 8.8% had intracranial extension.

CONCLUSIONS

Ophthalmologists may be the first who encounter these patients which necessitates familiarity with AFS presentations and complications. In cases of sudden visual loss, early intervention may prevent permanent vision loss. Functional endoscopic sinus surgery and postoperative systemic and topical steroids resulted in dramatic improvement of ophthalmic symptoms and signs.

Fungal infections of the orbit

Fungal infections of the orbit can lead to grave complications. Although the primary site of inoculation of the infective organism is frequently the sinuses, the patients can initially present to the ophthalmologist with ocular signs and symptoms. Due to its varied and nonspecific clinical features, especially in the early stages, patients are frequently misdiagnosed and even treated with steroids which worsen the situation leading to dire consequences. Ophthalmologists should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of this invasive sino-orbital infection. In this review, relevant clinical, microbiological, and imaging findings are discussed along with the current consensus on local and systemic management. We review the recent literature and provide a comprehensive analysis. In the immunocompromised, as well as in healthy patients, a high index of suspicion must be maintained as delay in diagnosis of fungal pathology may lead to disfiguring morbidity or even mortality. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly oral voriconazole and topical amphotericin B, may be beneficial in selected patients.

Allergic Aspergillus Rhinosinusitis

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

Allergic Fungal Sinusitis: Expanding the Clinicopathologic Spectrum

OBJECTIVE

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

RESULTS

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

CONCLUSION

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

SIGNIFICANCE

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

Allergic fungal sinusitis involving the lacrimal sac: a case report and review

BACKGROUNd: We report a case of allergic fungal sinusitis (AFS) involving the lacrimal sac and review the current English literature. A literature search for AFS involving the lacrimal sac revealed two reports with only one of the two cases demonstrating histological evidence of fungal elements. This is just the third such case and only the second reported case with histopathologic confirmation of fungal elements by Gomori methenamine silver (GMS) stain.

MATERIALS AND METHODS

A PubMed database search was performed using combinations of the following key words: allergic fungal sinusitis, lacrimal sac, nasolacrimal duct, ophthalmology, epiphora, orbit. A 70-year-old white man with a history of chronic conjunctivitis and nasal polyps presenting with chronic epiphora was found to have dacryostenosis on the left side. A CT scan of the orbits revealed mucoperiosteal thickening completely obliterating the frontal, ethmoid and sphenoid sinuses.

RESULTS

A left external dacryocystorhinostomy (DCR) was performed and the lacrimal sac contents were studied histopathologically. Microscopic examination of the lacrimal sac contents disclosed allergic mucin with laminated aggregates of eosinophils in various stages of degeneration, Charcot-Leyden crystals and rare noninvasive fungal hyphae confirming the diagnosis of AFS. Fungal elements stained positively with Gomori methenamine silver stain.

CONCLUSION

Although rarely reported, AFS can affect the lacrimal sac. AFS should be suspected in patients with a history of recurrent refractory sinusitis, recurrent dacryocystitis and nasal polyposis. Early diagnosis is important for adequate treatment and prevention of recurrence.

Neuro-ophthalmic manifestations of fungal disease associated with posthurricane environment

BACKGROUND

Allergic fungal sinusitis (AFS) is thought to represent an immunologic response to exposure to dematiaceous fungi. These fungi are known to cause disease more frequently in hot and humid climates and seasons.

METHODS

Three patients presented with unusual manifestations of fungal disease after exposure to environments recently affected by hurricanes.

RESULTS

Two patients had AFS, 1 with gradual painless visual loss from an AFS mass extending into the suprasellar region and 1 with orbital apex syndrome. Another patient had invasive fungal disease and developed orbital apex syndrome.

CONCLUSIONS

These cases underscore the importance of clinical recognition of fungal disease in patients with sinus, orbital, or skull base involvement as well as its potential for causing permanent visual loss. This report suggests a potential association between fungal disease and tropical storm exposure.

Allergic fungal sinusitis with massive intracranial extension presenting with tearing

A 24-year-old male presented with tearing, and subsequent workup and imaging showed a mass with fluid involving the nasopharynx, the paranasal sinuses, and the posterior dehiscence of the left frontal sinus intracranially compressing the frontal lobe significantly. Microscopic examination confirmed the diagnosis of allergic fungal sinusitis. Endoscopic drainage and sinostomy was performed by the otolaryngology (ear-nose-throat) service. The patient was followed 9 months postoperatively and did well with resolution of the epiphora. Although epiphora alone is an unusual presentation of allergic fungal sinusitis, ophthalmologists need to be aware of this entity, as it may invade the orbit through the sinus cavities or compress on the nasolacrimal duct before it causes other mass-related symptoms. Radiology and the characteristic histopathologic findings are the most useful in establishing the correct diagnosis.

Allergic fungal sinusitis: innocence under suspicion

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

Spectrum of fungal rhinosinusitis; histopathologist's perspective

AIMS

Clinical presentation can provide a clue to the subcategories of fungal rhinosinusitis (FRS); however, tissue examination provides accurate classification. The aim was to analyse the incidence and histopathological spectrum of FRS.

METHODS AND RESULTS

A retrospective analysis of all the cases of rhinosinusitis reported in the last 5 years was carried out. Haematoxylin and eosin-stained sections along with special stains such as periodic acid-Schiff and Grocott's were examined. These cases were subclassified based on the presence of allergic mucin, mycelial elements and tissue reaction. Out of a total of 665 cases of rhinosinusitis, 284 (42.7%) were of FRS. On histopathological examination they were broadly categorized as: (i) non-invasive FRS (n = 171, 60.2%), which included 160 cases (56.3%) of allergic fungal rhinosinusitis (AFRS) and eleven (3.9%) of fungal ball; (ii) invasive FRS (n = 101, 35.6%), which included 48 cases (16.9%) of chronic invasive granulomatous FRS, four (1.4%) of chronic invasive FRS and 49 (17.3%) of acute fulminant FRS; and (iii) mixed pattern FRS, comprising 12 cases (4.25%).

CONCLUSIONS

AFRS is the most common type of FRS. Cases with mixed reaction pattern suggest that different types of FRS represent a progressive spectrum of disease. An exact histopathological categorization of FRS is important as regards treatment.

Aspergillus flavus: an emerging non-fumigatus Aspergillus species of significance

Invasive aspergillosis is rare in immunocompetent people but contributes to significant morbidity and mortality in immunosuppressed patients. The majority (approximately 80%) of invasive Aspergillus infections is caused by Aspergillus fumigatus. The second most frequent (approximately 15-20%) pathogenic species is Aspergillus flavus and to a lesser extent, Aspergillus niger and Aspergillus terreus. Aspergillus flavus has emerged as a predominant pathogen in patients with fungal sinusitis and fungal keratitis in several institutions worldwide. To date, there has not been any publication exclusively reviewing the topic of A. flavus in the literature. This article reviews the microbiology, toxigenicity and epidemiology of A. flavus as well as describes the clinical characteristics, diagnosis and management of infections caused by this organism.

Controversies surrounding the categorization of fungal sinusitis

Though rhinosinusitis is a common disorder, controversies surround the categorization of chronic rhinosinusitis (CRS) and the role of fungus in CRS. The diagnosis of each category is important for optimum therapy and predicting the course. Based on histopathological findings, fungal rhinosinusitis (FRS) can be broadly divided into two categories: the invasive and non-invasive depending on invasion of the mucosal layer. Three types of FRS are tissue-invasive: acute invasive, chronic invasive, & granulomatous. The two non-invasive FRS disorders are fungal ball, and fungus related eosinophilic rhinosinusitis including allergic fungal rhinosinusitis (AFRS). The distinction of granulomatous from chronic invasive type is not beyond controversy as both types have a chronic course and predominant orbital involvement. Maximum confusion surrounds the entity of fungus-related eosinophilic rhinosinusitis, and the definition of AFRS. In the diagnosis of AFRS, the detection of fungi in allergic mucin is considered important, although hyphae are sparse in sinus content. This leads to confusion in definition of this entity, especially with the description of two more closely related entities--eosinophilic fungal rhinosinusitis (EFRS) and eosinophilic mucin rhinosinusitis (EMRS). Recently reports of histologic invasion in possible cases of AFRS were also documented. Currently, there are more questions than answers concerning the categorization of FRS.

Management of allergic fungal sinusitis with intracranial spread

Allergic fungal sinusitis (AFS) is a form of paranasal nasal disease if not managed early often involves bone destruction and extension into the orbit and anterior skull base. We present our study of patients with AFS with intracranial, exdradural extension. This study includes our experience of 26 patients with the histological and immunological diagnosis of AFS based on findings of branching septate fungi interspersed with eosinophilic mucin and Charcot-Leyden crystals without fungal invasion of soft tissue, with intracranial extension. All had erosion of bone, which was observed on computerized tomography (CT) scans, extending intracranially and eight had disease that additionally involved the lamina papyracea. The average age of patients in this study was 25 years (range 9-46). There were 20 male and 6 female patients. All patients were immunocompetent. Skin test against aspergillin showed all patients had Type 1 hypersensitivity. All patients underwent transnasal and/or transmaxillary endoscopic approaches for debridement and eight underwent orbital decompression. No patient underwent craniotomy for removal of intracranial extradural disease. No patient had a cerebrospinal fluid leak. Postoperatively, all 26 were treated with a course of corticosteroids. The follow-up period ranged from 2 to 5 years. We conclude AFS is a unique form of fungal disease that might mimic anterior skull base and paranasal sinus tumors. Most cases can be successfully managed with transnasal and/or transmaxillary endoscopic techniques.

Response of visual loss in allergic fungal sinusitis to oral corticosteroids

Visual loss associated with allergic fungal sinusitis is most often treated with surgery followed by oral corticosteroids. A case is presented in which, because of substantial medical comorbidities, surgery could not be initially performed and the visual loss was corrected with prednisone alone. This case serves to reinforce the central role of corticosteroids in treatment of this enigmatic condition.

Overview of fungal rhinosinusitis

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

Allergic fungal sinusitis

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

Neurosurgical implications of allergic fungal sinusitis

OBJECT

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

METHODS

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

CONCLUSIONS

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

Current perspectives on ophthalmic mycoses

Fungi may infect the cornea, orbit and other ocular structures. Species of Fusarium, Aspergillus, Candida, dematiaceous fungi, and Scedosporium predominate. Diagnosis is aided by recognition of typical clinical features and by direct microscopic detection of fungi in scrapes, biopsy specimens, and other samples. Culture confirms the diagnosis. Histopathological, immunohistochemical, or DNA-based tests may also be needed. Pathogenesis involves agent (invasiveness, toxigenicity) and host factors. Specific antifungal therapy is instituted as soon as the diagnosis is made. Amphotericin B by various routes is the mainstay of treatment for life-threatening and severe ophthalmic mycoses. Topical natamycin is usually the first choice for filamentous fungal keratitis, and topical amphotericin B is the first choice for yeast keratitis. Increasingly, the triazoles itraconazole and fluconazole are being evaluated as therapeutic options in ophthalmic mycoses. Medical therapy alone does not usually suffice for invasive fungal orbital infections, scleritis, and keratitis due to Fusarium spp., Lasiodiplodia theobromae, and Pythium insidiosum. Surgical debridement is essential in orbital infections, while various surgical procedures may be required for other infections not responding to medical therapy. Corticosteroids are contraindicated in most ophthalmic mycoses; therefore, other methods are being sought to control inflammatory tissue damage. Fungal infections following ophthalmic surgical procedures, in patients with AIDS, and due to use of various ocular biomaterials are unique subsets of ophthalmic mycoses. Future research needs to focus on the development of rapid, species-specific diagnostic aids, broad-spectrum fungicidal compounds that are active by various routes, and therapeutic modalities which curtail the harmful effects of fungus- and host tissue-derived factors.

Fungal peritonitis caused byBipolaris spicifera

An episode of fungal peritonitis was produced by Bipolaris spicifera in a 3-year-old girl with chronic renal failure secondary to uremic-hemolytic syndrome and who was under treatment with continuous ambulatory peritoneal dialysis (CAPD). Previously, an episode of purulent peritonitis caused by Pseudomonas spp. had been treated successfully with combined antibacterial therapy for 10 days. Microscopic and macroscopic examinations of the freshly collected purulent dialysate were negative for fungal structures and bacteria. The fungus grew from the dialysate plated on Sabouraud dextrose agar and was also macroscopically recognized as a colony attached to the inner wall of the Tenckhoff catheter. Specific cultures of dialysate for common bacteria and mycobacteria were negative. The patient was successfully treated with early catheter removal and empirical administration of 200 mg/day oral fluconazole for 2 weeks. Subsequently, a new catheter was placed and the patient continued well on CAPD. Post-treatment control cultures of dialysate for fungi, bacteria and mycobacteria were negative and the cell count returned to normal.

Clinical presentation of allergic fungal sinusitis in children

OBJECTIVE

To compare the differences in the clinical and radiographic presentation of allergic fungal sinusitis in children and adults.

STUDY DESIGN

Retrospective chart and computed tomography review.

METHODS

The settings included a tertiary care children's hospital, adult academic private hospital, and academic affiliated county hospital. All patients with documented allergic fungal sinusitis who underwent computed tomography evaluation and had surgical treatment of their disease from 1988 to 1999 were included in the study. In total, 151 patients aged 5 to 75 years; 44 of these patients were less than or equal to 17 years of age (children) and 107 were greater than 17 years of age (adults). Main outcome measures included 1) the presence of obvious bony facial abnormalities on presentation, 2) bilateral or unilateral sinus disease on presentation, 3) the presence of asymmetrical disease on presentation, 4) the presence of bony extension on computed tomography scan, and 5) type of fungus present.

RESULTS

Fifteen of 36 (42%) pediatric patients and 10 of 103 (10%) adult patients had obvious alteration of their facial skeleton (proptosis, telecanthus, or malar flattening) on presentation (P <.05). Proptosis was the most common facial abnormality in both groups and was seen more often in children (8 of 36 [22%]) than in adults (9 of 103 [9%]) (P <.05). Twenty-eight of 40 (70%) pediatric patients and 37 of 100 (37%) adult patients presented with unilateral sinus disease (P <.05). Thirty-five of 40 (88%) pediatric patients and 58 of 100 (58%) adults presented with asymmetrical disease (P <.05). Computed tomography scans showed that 10 of 40 (25%) pediatric patients and 23 of 100 (23%) adult patients had bony erosion with extension of disease into surrounding structures (P >.05). Cultures from both adults and children showed mainly Bipolaris and Curvilaria species in equal amounts (P >.05). Adults had a greater incidence of Aspergillus species.

CONCLUSIONS

Presentation in pediatric patients with allergic fungal sinusitis is different from that in adults, with children having obvious abnormalities of their facial skeleton, unilateral sinus disease, and asymmetrical disease more often. Findings on computed tomography scan show an equal amount of bony erosion with extension of disease. The types of fungus cultured in the sinus cavities are similar in both groups.

Allergic fungal rhinosinusitis: current theories and management strategies

The combination of nasal polyposis, crust formation, and sinus cultures yielding Aspergillus was first noted in 1976 by Safirstein,1 who observed the clinical similarity that this constellation of findings shared with allergic bronchopulmonary Aspergillosis (ABPA). Eventually this disease came to be known as allergic fungal rhinosinusitis (AFS). As clinical evidence of AFS accumulated, controversy regarding its etiology, pathogenesis, natural history, and appropriate treatment naturally emerged. Despite past and current efforts, many of these controversies remain incompletely resolved, but continuing clinical study has illuminated some aspects of the disease and has led to an improved understanding of AFS and its treatment. Fungi associated with the development of AFS are ubiquitous and predominantly of the dematiaceous family. The eosinophilic host response to the presence of these fungi within the nose and paranasal sinuses gives rise to those clinical manifestations of the disease (nasal polyps, expansile mucocele formation, allergic fungal mucin, etc.). Exposure alone to these fungi, however, appears to be insufficient to initiate the disease. At the present time it is likely that initiation of the inflammatory cascade leading to AFS is a multifactorial event, requiring the simultaneous occurrence of such things as IgE-mediated sensitivity (atopy), specific T-cell HLA receptor expression, exposure to specific fungi, and aberration of local mucosal defense mechanisms. A variety of treatment plans for AFS have emerged, but the potential for recidivism remains well recognized, ranging from 10% to nearly 100%, suggesting the need for continued study of this disease and fueling present controversy. This article is intended to review current data and theories regarding the pathophysiology of AFS, as well as the role of various surgical and nonsurgical forms of therapy.

Characteristics of bony erosion in allergic fungal rhinosinusitis

OBJECTIVES

Erosion of bone with or without extension of disease into adjacent anatomic spaces is observed among some patients with allergic fungal rhinosinusitis (AFRS). The objective of this report is to further define these findings as they relate to this disease.

STUDY DESIGN

Retrospective chart review of 142 patients with AFRS diagnosed using the Bent-Kuhn criteria. All patients were treated at a single institution.

RESULTS

Approximately 20% of patients with AFRS demonstrated bone erosion on CT scan. The ethmoid sinus was the most commonly eroded site. The orbit and anterior cranial fossa were the most common adjacent anatomic spaces to exhibit disease extension. Sinus expansion, not the specific organism identified, was associated with the presence of bone erosion. Surgical management with endoscopic techniques was successful for all patients without any major perioperative complications.

CONCLUSION

Bone erosion can be related to AFR. Recognition of this possibility is important because bone erosion can be interpreted as an indication of invasive pathosis. In the presence of bone erosion or disease extension, endoscopic techniques can be used to surgically manage this disease.

Allergic fungal rhinosinusitis: surgical management

Allergic fungal sinusitis is a newly characterized disease entity that has commanded a great deal of interest over the past 2 decades. As more information is gathered about its underlying etiology, clinical presentation, and response to therapy, the treatment of allergic fungal sinusitis is becoming more refined. Most current treatment protocols for allergic fungal sinusitis are based upon a combined surgical and medical approach. This article addresses pertinent surgical aspects as related to the management of allergic fungal sinusitis.

Ophthalmic manifestations of allergic fungal sinusitis

PURPOSE

To highlight allergic fungal sinusitis as a cause of ophthalmic and sinus problems by identifying the profile of the patient with allergic fungal sinusitis and presenting a successful treatment approach.

METHODS

Six consecutive cases of patients with ophthalmic manifestations of allergic fungal sinusitis were reviewed. Ophthalmic findings, sinus involvement, mycology, immune response, imaging studies, and treatment were examined. The characteristics of this patient group with ophthalmic manifestations of allergic fungal sinusitis were compared with those of the general group of patients with allergic fungal sinusitis.

RESULTS

All six patients had proptosis. One had symptomatic diplopia and one had visual loss. Imaging studies, fungal characterization, and immune profiles were similar to the reported allergic fungal sinusitis population. After treatment there was no recurrence of ophthalmic or sinus symptoms at a mean follow-up of 34 months (range, 8 to 48 months). There were no complications of treatment.

CONCLUSIONS

Initial diagnosis of allergic fungal sinusitis requires suspicion on the part of the ophthalmologist. Proptosis is the most common ophthalmic sign. Differentiation from invasive forms of fungal sinus disease is crucial, because systemic antifungal medication and extensive surgical tissue debridement are not required in allergic fungal sinusitis. Treatment consists of extirpation of the allergic mucin and fungus, sinus aeration, and systemic and topical corticosteroids.