Skip to main content

Advertisement

SpringerLink
Log in

Managing Allergic Fungal Rhinosinusitis

  • RHINOLOGY: Chronic Rhinosinusitis (C Philpott, Section Editor)
  • Published:
Current Otorhinolaryngology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Management of the patient with allergic fungal rhinosinusitis (AFRS) requires detailed understanding of the pathophysiology and clinical manifestation of the disease. Treatment options and outcomes are evolving and this review enables the otolaryngologist to have a fulsome discussion of the treatment options and expectations of the disease course with the patient.

Recent Findings

Since first described over 30 years ago, no single treatment modality has been found to be curative and managing the disease remains challenging. Ongoing research to improve outcomes with new rinses and light therapy particularly for the recalcitrant patient is described in this review.

Summary

AFRS is a challenging disease to diagnose and treat. A commitment has to be made by both the surgeon and patient for continued follow-up after good surgery. Early recognition of disease relapse and the knowledge of the options available are paramount to reduce the need for multiple surgical intervention and maintenance of a good quality of life.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Safirstein BH. Allergic bronchopulmonary aspergillosis with obstruction of the upper respiratory tract. Chest. 1976;70:788–90.

    Article  PubMed  CAS  Google Scholar 

  2. Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Thorax. 2015;70:270–7.

    Article  PubMed  Google Scholar 

  3. Agarwal R. Allergic bronchopulmonary aspergillosis. Chest. 2009;135:805–26.

    Article  PubMed  Google Scholar 

  4. Katzenstein AL, Sale SR, Greenberger PA. Allergic Aspergillus sinusitis: a newly recognized form of sinusitis. J Allergy Clin Immunol. 1983;72:89–93.

    Article  PubMed  CAS  Google Scholar 

  5. Shah A, Panchal N, Agarwal AK. Concomitant allergic bronchopulmonary aspergillosis and allergic Aspergillus sinusitis: a review of an uncommon association. Clin Exp Allergy. 2001;31:1896–905.

    Article  PubMed  CAS  Google Scholar 

  6. Robson JM, Hogan PG, Benn RA, Gatenby PA. Allergic fungal sinusitis presenting as a paranasal sinus tumour. Aust NZ J Med. 1989;19:351–3.

    Article  CAS  Google Scholar 

  7. Manning SC, Schaefer SD, Close LG, Vuitch F. Culture-positive allergic fungal sinusitis. Arch Otolaryngol Head Neck Surg. 1991;117:174–8.

    Article  PubMed  CAS  Google Scholar 

  8. Chakrabarti A, Rudramurthy SM, Panda N, Das A, Singh A. Epidemiology of chronic fungal rhinosinusitis in rural India. Mycoses. 2015;58:294–302.

    Article  PubMed  Google Scholar 

  9. Taj-Aldeen SJ, Hilal AA, Schell WA. Allergic fungal rhinosinusitis: a report of 8 cases. Am J Otolaryngol. 2004;25:213–8.

    Article  PubMed  Google Scholar 

  10. Granville L, Chirala M, Cernoch P, Ostrowski M, Truong LD. Fungal sinusitis: histologic spectrum and correlation with culture. Hum Pathol. 2004;35:474–81.

    Article  PubMed  Google Scholar 

  11. Schubert MS. Allergic fungal sinusitis: pathophysiology, diagnosis and management. Med Mycol. 2009;47(Suppl 1):S324–30.

    Article  PubMed  CAS  Google Scholar 

  12. Kuhn FA, Javer AR. Allergic fungal rhinosinusitis: perioperative management, prevention of recurrence, and role of steroids and antifungal agents. Otolaryngol Clin N Am. 2000;33:419–33.

    Article  CAS  Google Scholar 

  13. Ferguson BJ, Barnes L, Bernstein JM, et al. Geographic variation in allergic fungal rhinosinusitis. Otolaryngol Clin N Am. 2000;33:441–9.

    Article  CAS  Google Scholar 

  14. Wise SK, Ghegan MD, Gorham E, Schlosser RJ. Socioeconomic factors in the diagnosis of allergic fungal rhinosinusitis. Otolaryngol Head Neck Surg. 2008;138:38–42.

    Article  PubMed  Google Scholar 

  15. Manning SC, Holman M. Further evidence for allergic pathophysiology in allergic fungal sinusitis. Laryngoscope. 1998;108:1485–96.

    Article  PubMed  CAS  Google Scholar 

  16. Romani L. Immunity to fungal infections. Nat Rev Immunol. 2011;11:275–88.

    Article  PubMed  CAS  Google Scholar 

  17. Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. Otolaryngol Head Neck Surg. 2004;131:S1–62.

    Article  PubMed  Google Scholar 

  18. Ghegan MD, Lee FS, Schlosser RJ. Incidence of skull base and orbital erosion in allergic fungal rhinosinusitis (AFRS) and non-AFRS. Otolaryngol Head Neck Surg. 2006;134:592–5.

    Article  PubMed  Google Scholar 

  19. Ponikau JU, Sherris DA, Kern EB, et al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc. 1999;74:877–84.

    Article  PubMed  CAS  Google Scholar 

  20. Ponikau JU, Sherris DA, Kephart GM, et al. Striking deposition of toxic eosinophil major basic protein in mucus: implications for chronic rhinosinusitis. J Allergy Clin Immunol. 2005;116:362–9.

    Article  PubMed  CAS  Google Scholar 

  21. Ferguson BJ. Eosinophilic mucin rhinosinusitis: a distinct clinicopathological entity. Laryngoscope. 2000;110:799–813.

    Article  PubMed  CAS  Google Scholar 

  22. Bent JP 3rd, Kuhn FA. Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1994;111:580–8.

    Article  PubMed  Google Scholar 

  23. Philpott CM, Javer AR, Clark A. Allergic fungal rhinosinusitis—a new staging system. Rhinology. 2011;49:318–23.

    PubMed  CAS  Google Scholar 

  24. Guo C, Ghadersohi S, Kephart GM, et al. Improving the detection of fungi in eosinophilic mucin: seeing what we could not see before. Otolaryngol Head Neck Surg. 2012;147:943–9.

    Article  PubMed  Google Scholar 

  25. Manning SC, Merkel M, Kriesel K, Vuitch F, Marple B. Computed tomography and magnetic resonance diagnosis of allergic fungal sinusitis. Laryngoscope. 1997;107:170–6.

    Article  PubMed  CAS  Google Scholar 

  26. Reddy CE, Gupta AK, Singh P, Mann SB. Imaging of granulomatous and chronic invasive fungal sinusitis: comparison with allergic fungal sinusitis. Otolaryngol Head Neck Surg. 2010;143:294–300.

    Article  PubMed  Google Scholar 

  27. Kuhn FA, Javer AR. Allergic fungal rhinosinusitis: our experience. Arch otolaryngol Head Neck Surg. 1998;124:1179–80.

    Article  PubMed  CAS  Google Scholar 

  28. Gan EC, Thamboo A, Rudmik L, Hwang PH, Ferguson BJ, Javer AR. Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations. Int Forum Allergy Rhinol. 2014;4:702–15.

    Article  PubMed  Google Scholar 

  29. Poetker DM, Jakubowski LA, Lal D, Hwang PH, Wright ED, Smith TL. Oral corticosteroids in the management of adult chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2013;3:104–20.

    Article  PubMed  Google Scholar 

  30. Landsberg R, Segev Y, DeRowe A, Landau T, Khafif A, Fliss DM. Systemic corticosteroids for allergic fungal rhinosinusitis and chronic rhinosinusitis with nasal polyposis: a comparative study. Otolaryngol Head Neck Surgery. 2007;136:252–7.

    Article  Google Scholar 

  31. Ikram M, Abbas A, Suhail A, Onali MA, Akhtar S, Iqbal M. Management of allergic fungal sinusitis with postoperative oral and nasal steroids: a controlled study. Ear Nose Throat J. 2009;88:E8–11.

    PubMed  Google Scholar 

  32. Kuhn FA, Javer AR. Allergic fungal sinusitis: a four-year follow-up. Am J Rhinol. 2000;14:149–56.

    Article  PubMed  CAS  Google Scholar 

  33. Poetker DM, Reh DD. A comprehensive review of the adverse effects of systemic corticosteroids. Otolaryngol Clin N Am. 2010;43:753–68.

    Article  Google Scholar 

  34. Ryan MW. Allergic fungal rhinosinusitis. Otolaryngol Clin N Am. 2011;44:697–710. ix-x

    Article  Google Scholar 

  35. Thamboo A, Manji J, Szeitz A, et al. The safety and efficacy of short-term budesonide delivered via mucosal atomization device for chronic rhinosinusitis without nasal polyposis. Int Forum Allergy Rhinol. 2014;4:397–402.

    Article  PubMed  Google Scholar 

  36. Rudmik L, Hoy M, Schlosser RJ, et al. Topical therapies in the management of chronic rhinosinusitis: an evidence-based review with recommendations. Int forum allergy rhinol. 2013;3:281–98.

    Article  PubMed  Google Scholar 

  37. Joe SA, Thambi R, Huang J. A systematic review of the use of intranasal steroids in the treatment of chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2008;139:340–7.

    Article  PubMed  Google Scholar 

  38. Habib AR, Thamboo A, Manji J, et al. The effect of head position on the distribution of topical nasal medication using the Mucosal Atomization Device: a cadaver study. Int Forum Allergy Rhinol. 2013;3:958–62.

    Article  PubMed  Google Scholar 

  39. Smith KA, French G, Mechor B, Rudmik L. Safety of long-term high-volume sinonasal budesonide irrigations for chronic rhinosinusitis. Int Forum Allergy Rhinol. 2016;6:228–32.

    Article  PubMed  Google Scholar 

  40. Soudry E, Wang J, Vaezeafshar R, Katznelson L, Hwang PH. Safety analysis of long-term budesonide nasal irrigations in patients with chronic rhinosinusitis post endoscopic sinus surgery. Int Forum Allergy Rhinol. 2016;6:568–72.

    Article  PubMed  Google Scholar 

  41. Manji J, Singh G, Okpaleke C, et al. Safety of long-term intranasal budesonide delivered via the mucosal atomization device for chronic rhinosinusitis. Int Forum Allergy Rhinology. 2017;7:488–93.

    Article  Google Scholar 

  42. Thamboo A, Thamboo A, Philpott C, Javer A, Clark A. Single-blind study of manuka honey in allergic fungal rhinosinusitis. J Otolaryngol Head Neck Surgery. 2011;40:238–43.

    Google Scholar 

  43. Seiberling K, Wormald PJ. The role of itraconazole in recalcitrant fungal sinusitis. Am J Rhinol Allergy. 2009;23:303–6.

    Article  PubMed  Google Scholar 

  44. Rains BM 3rd, Mineck CW. Treatment of allergic fungal sinusitis with high-dose itraconazole. Am J Rhinol. 2003;17:1–8.

    Article  PubMed  Google Scholar 

  45. Cody DT 2nd, Neel HB 3rd, Ferreiro JA, Roberts GD. Allergic fungal sinusitis: the Mayo Clinic experience. Laryngoscope. 1994;104:1074–9.

    Article  PubMed  Google Scholar 

  46. Chan KO, Genoway KA, Javer AR. Effectiveness of itraconazole in the management of refractory allergic fungal rhinosinusitis. J Otolaryngol Head Neck Surgery. 2008;37:870–4.

    Google Scholar 

  47. Khalil Y, Tharwat A, Abdou AG, et al. The role of antifungal therapy in the prevention of recurrent allergic fungal rhinosinusitis after functional endoscopic sinus surgery: a randomized, controlled study. Ear, Nose, Throat J. 2011;90:E1–7.

    Google Scholar 

  48. Dumortier G, Grossiord JL, Agnely F, Chaumeil JC. A review of poloxamer 407 pharmaceutical and pharmacological characteristics. Pharm Res. 2006;23:2709–28.

    Article  PubMed  CAS  Google Scholar 

  49. Lanker Klossner B, Widmer HR, Frey F. Nondevelopment of resistance by bacteria during hospital use of povidone-iodine. Dermatology (Basel, Switzerland). 1997;195(Suppl 2):10–3.

    Article  Google Scholar 

  50. Kim JH, Rimmer J, Mrad N, Ahmadzada S, Harvey RJ. Betadine has a ciliotoxic effect on ciliated human respiratory cells. J Laryngol Otol. 2015;129(Suppl 1):S45–50.

    Article  PubMed  Google Scholar 

  51. Mullings W, Rikesh Panchmatia KS, Habib A-R, Thamboo A, Javer RA-SA. Topical povidone-iodine in recalcitrant chronic rhinosinusitis: an adjunctive treatment to endoscopic evidence of infection. London: Congress of the European Rhinologic Society; 2018. p. 2018.

    Google Scholar 

  52. Biel MA, Sievert C, Usacheva M, Teichert M, Balcom J. Antimicrobial photodynamic therapy treatment of chronic recurrent sinusitis biofilms. Int Forum Allergy Rhinol. 2011;1:329–34.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Biel MA, Jones JW, Pedigo L, Gibbs A, Loebel N. The effect of antimicrobial photodynamic therapy on human ciliated respiratory mucosa. Laryngoscope. 2012;122:2628–31.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  54. Doellman MS, Dion GR, Weitzel EK, Reyes EG. Immunotherapy in allergic fungal sinusitis: the controversy continues. A recent review of literature. Allergy Rhinol (Providence, RI). 2013;4:e32–5.

    Article  Google Scholar 

  55. Hall AG, deShazo RD. Immunotherapy for allergic fungal sinusitis. Curr Opin Allergy Clin Immunol. 2012;12:629–34.

    Article  PubMed  CAS  Google Scholar 

  56. Mabry RL, Mabry CS. Immunotherapy for allergic fungal sinusitis: the second year. Otolaryngol Head Neck Surg. 1997;117:367–71.

    Article  PubMed  CAS  Google Scholar 

  57. Mabry RL, Marple BF, Folker RJ, Mabry CS. Immunotherapy for allergic fungal sinusitis: three years’ experience. Otolaryngol Head Neck Surg. 1998;119:648–51.

    Article  PubMed  CAS  Google Scholar 

  58. Folker RJ, Marple BF, Mabry RL, Mabry CS. Treatment of allergic fungal sinusitis: a comparison trial of postoperative immunotherapy with specific fungal antigens. Laryngoscope. 1998;108:1623–7.

    Article  PubMed  CAS  Google Scholar 

  59. Marple B, Newcomer M, Schwade N, Mabry R. Natural history of allergic fungal rhinosinusitis: a 4- to 10-year follow-up. Otolaryngol Head Neck Surg. 2002;127:361–6.

    Article  PubMed  Google Scholar 

  60. Gan EC, Habib AR, Rajwani A, Javer AR. Omalizumab therapy for refractory allergic fungal rhinosinusitis patients with moderate or severe asthma. Am J Otolaryngol. 2015;36:672–7.

    Article  PubMed  Google Scholar 

  61. Rivero A, Liang J. Anti-IgE and anti-IL5 biologic therapy in the treatment of nasal polyposis: a systematic review and meta-analysis. Ann Otol RhinolLaryngol. 2017;126:739–47.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. St Paul’s Sinus Centre, St Paul’s Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, V6Z 1Y6, Canada

    Warren P. Mullings, Rami Al-Salman & Amin R. Javer

Authors
  1. Warren P. Mullings
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rami Al-Salman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Amin R. Javer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Amin R. Javer.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

The studies by the authors referenced in this article have all received ethical board approval and the participants' full informed consent.

Additional information

This article is part of the Topical Collection on RHINOLOGY: Chronic Rhinosinusitis

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mullings, W.P., Al-Salman, R. & Javer, A.R. Managing Allergic Fungal Rhinosinusitis. Curr Otorhinolaryngol Rep 6, 263–270 (2018). https://doi.org/10.1007/s40136-018-0206-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40136-018-0206-4

Keywords

Search

Navigation