Recurrence Pattern and Complication Rate of Allergic Fungal Sinusitis: A 10-Year Tertiary Center Experience

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.

Outcomes of Functional Endoscopic Sinus Surgery in Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis

Chronic rhinosinusitis (CRS) is a prevalent health problem that affects many people around the world and can require surgical intervention if conservative therapy fails. Functional endoscopic sinus surgery (FESS) is a minimally invasive surgical procedure commonly used to manage CRS. The success of FESS depends on various factors, and larger studies are necessary to determine its efficacy in managing CRS in this population. This systematic review and meta-analysis of the available literature aims to provide a comprehensive assessment of the effectiveness of FESS in the Middle East. We followed the standards outlined by PRISMA and the Cochrane Handbook for systematic reviews. The primary outcome of interest was the quality of life (QOL), and the secondary outcome was the recurrence of CRS. This systematic review and meta-analysis was conducted, and sensitivity analysis was performed to examine the robustness of the results. Six studies were included. The review found that the QOL significantly improved (p < 0.001). Two studies reported recurrence of CRS after FESS, and data showed that the recurrence of CRS after surgery was 6%. FESS is an effective intervention for CRS, but further research is needed on recurrence rates.

The Rate and Predictors of Allergic Fungal Rhinosinusitis Recurrence Post-sinus Surgery: A Retrospective Cohort Study

Objectives Chronic rhinosinusitis (CRS) is the persistent inflammation of the mucosal lining of the paranasal sinuses (PNS). By definition, the inflammatory process persists beyond 12 weeks. One of its subtypes is allergic fungal rhinosinusitis (AFRS), which has a high risk of recurrence, leading to revision surgery. This study aimed to establish the predictive factors for the recurrence of AFRS in post-sinus surgery patients. Methods This single-center retrospective study was conducted in Al-Noor Specialist Hospital, Makkah, Saudi Arabia. The charts of patients with AFRS who underwent surgery in our rhinology clinic between 2000 and 2020 were reviewed. Results Among the 116 patients included in this study, approximately half (53%) were female, with a median age of 24.5 years. Thirty-nine (33.6%) patients had recurrence post-sinus surgery, with 33.3% occurring within six months of follow-up. The results showed that patients with coexisting bronchial asthma were three times more likely to experience recurrence (adjusted odds ratio {AOR}, 3.43; confidence interval {CI}, 1.35-8.71), patients with uncorrected deviated nasal septum (DNS) were three times more likely to experience symptoms again following surgery (AOR, 3.70; CI, 1.14-12.02), and patients who presented with concomitant sinus headaches are 66% less likely to experience recurrence (AOR, 0.34; CI, 0.13-0.86). Conclusion The results showed that 33.62% of patients experienced recurrence following surgery. Bronchial asthma and DNS were strongly associated with recurrence; however, their presence does not always imply the need for additional surgery.

Orbital Complications of Extensive Allergic Fungal Rhinosinusitis: A Case Report

Allergic fungal rhinosinusitis is an immunoglobulin E-mediated disease caused by fungal antigens. Orbital complications due to bone erosion by the expanding, mucin-filled sinuses are considered uncommon, but they require immediate intervention. We report a successful management of a complicated case of allergic fungal rhinosinusitis in a 16-year-old female complaining of progressive nasal obstruction for four months, who only sought medical advice after developing proptosis and visual affection. The patient underwent surgical debridement and corticosteroid therapy followed by dramatic improvement of proptosis and vision. The differential diagnosis of proptosis with sinusitis must include allergic fungal rhinosinusitis.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Successful Use of Dupilumab as a Salvage Therapy for Recalcitrant Allergic Fungal Rhinosinusitis: A Case Report

Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis with nasal polyps (CRSwNP) which is distinguished by the presence of eosinophilic mucin, type 1 hypersensitivity reaction resulting from fungi residing within the sinus, and characteristic imaging findings of the paranasal sinuses. Surgical intervention, sinonasal irrigations, and topical and systemic medications are commonly used to reduce the fungal load and antigenic stimulation. Despite the advancement of medical and surgical management of AFRS, a high recurrence rate is still a significant concern. The proper treatment for refractory AFRS remains controversial. Herein, we discuss the use of dupilumab for controlling refractory AFRS. We report a case of a 33-year-old female patient known to have had AFRS for 16 years. Due to the recurring nature of her illness, 16 functional endoscopic sinus surgeries (FESS) have been done to control her symptoms. The last operation was done in our institution; evidence for cure was insufficient with the persistence of symptoms. After a consensus decision with the multidisciplinary management team, she was an appropriate candidate for therapy with dupilumab. After six months of using the medication, magnificent improvement and control of symptoms were noted, and post-treatment CT scans illustrated excellent progression from previous scans. AFRS could be an extremely debilitating disease with significant impairment of quality of life even when standard therapy and extensive surgical interventions are implemented. Dupilumab can be an excellent option as a salvage therapy for recalcitrant AFRS with significant improvement in patients' quality of life and resolution of symptoms.

Allergic Fungal Rhinosinusitis in Saudi Arabia: A Review of Recent Literature

Allergic fungal rhinosinusitis (AFRS) has been considered an enigma since it was first described four decades ago. Previous research has found that AFRS has multiple definitions and a poorly understood pathogenesis because it overlaps with other conditions and necessitates meticulous work and multiple diagnostic modalities to confirm the diagnosis. However, despite the expansion of medical and surgical treatments, recurrence still occurs. In this review, the recent literature on AFRS cases in Saudi Arabia with relevance to its epidemiology, diagnosis, and management was studied and compared with international data. PubMed, Google Scholar, and Cochrane Library were searched for original research and review articles with local data. There is an evident paucity and contradiction between local studies regarding the epidemiology, diagnostic methods, and management of AFRS. Hence, well-defined randomized controlled trials (RCTs) are needed for the treatment of this chronic recurrent disease.