fungal sinusitis-summary from AAAAI meeting Anaheim oct 05

[Guest guest]

http://www.medscape.com/viewarticle/468789

_________________________________________

Allergic Fungal Sinusitis (AFS)

Bradley F. Marple, MD,[13] of the Department of Otolaryngology, University of

Texas

Southwestern Medical Center, Dallas, Texas, urged attendees to think about

sinusitis as

similar to an abscess. Therefore, treatment principles would include drainage,

maintaining

sinus opening (ostial) patency, and appropriate use of antibiotics.

The incidence of AFS is unknown. This may be due to a number of factors,

including a lack

of recognition, failure to appropriately culture, and various changes in fungal

taxonomy.

Primary diagnostic criteria for AFS include:

*

History of radiologically documented chronic sinusitis of at least 6-months

duration

*

History and physical examination do not suggest another etiology

*

Nasal polyposis

*

Characteristic CT or MRI findings

*

Mucin from the sinus typical for AFS (essential)

*

Absence of fungal tissue invasion (essential)

*

Presence of fungus in allergic mucin demonstrated by histology and/or culture

(newer

fluorescein-labeled staining method to detect chitin found in fungal cell walls

is more

consistent than previous staining methods)

*

History of allergic disease demonstrated by specific immunoglobulin (Ig) E

(usually

present)

*

Indicative laboratory findings

The clinical presentation of AFS may have an indolent course, with patients

having a mean

age of 21.9 years.[14] Between 60% and 70% have an atopic history, with 50%

having

asthma.[14] There is no linkage to aspirin-sensitive " Samter's triad "

asthma.[14] The

clinical history may be subtle, and, surprisingly, headache is typically absent.

There is

often nasal obstruction, and there may be visual disturbance.[12] The physical

examination findings may be dramatic, with nasal polyposis, and facial deformity

with

telecanthus, proptosis, and maxillary area fullness.[12]

Sinus CT scan findings may include the presence of an allergic mucin mucocele,

associated

obstructive sinusitis, and a multidensity appearance to the sinus obstructive

material

(which contains calcium, chelated iron, and manganese).[15] Of concern, there

may be

intracranial or orbital extension of this process.

There is conflicting evidence regarding the importance of positive fungal

cultures in

patients with chronic sinusitis. Some promising early research from the Mayo

Clinic

involving antifungal treatment for patients with chronic rhinosinusitis may

provide an

additional tool for managing this disorder. The role of fungal infection or

colonization in

the pathogenesis of chronic rhinosinusitis clearly warrants further research.

Because

fungal sinusitis is not a common disorder, the clinician needs to have an index

of

suspicion in order to correctly identify patients with this disease.

References:

Manning SC, Schaefer SD, Close LG, Vuitch F. Culture-positive allergic fungal

sinusitis.

Arch Otolaryngol Head Neck Surg. 1991;117:174-178. Abstract

Marple BF. New developments in the medical management of rhinosinusitis.

Allergic

fungal sinusitis. Program and abstracts of the American College of Allergy,

Asthma &

Immunology 2003 Annual Meeting; November 7-12, 2003; New Orleans, Louisiana.

Manning SC, Holman M. Further evidence for allergic pathophysiology in

allergic

fungal sinusitis. Laryngoscope. 1998;108:1485-1496. Abstract

Mukherji SK, Figueroa RE, Ginsberg LE, et al. Allergic fungal sinusitis: CT

findings.

Radiology. 1998;207:417-422. Abstract