Allergic Fungal Rhinosinusitis


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Allergic Fungal Rhinosinusitis

  1. 1. Allergic Fungal Rhino sinusitisDr Sudhir HalikarConsultant & Head Dept of ENTPUNE, Maharashtra
  2. 2. AFRS is an allergic reaction toaerosolized environmentalfungi with allergic mucinousresponse in nonimmunocompromisedpatients.
  3. 3. Incidence5 – 10% patients of chronicrhinosinusitiesCommon in tropical countriesMore in young age2/3rdpatients reported h/o allergic rhinitis
  4. 4. HistoryDecades ago fungal infection of nose isconsidered as deadly fungal diseaseIn 1976 Safirstein noted polyposis ,crust formation & aspergillus in culturesimilar to Allergic bronchopulmonaryaspergillosis[ABPA]In 1989 Robson coined the termAllergic Fungal Sinusitis
  5. 5. MycologyDematicious fungiBipolaries spiciferaAlternariaDreschleraCurvalariaHyaline mouldsAspergillus
  6. 6. AFRS PathologyAbsence of fungal mycelia in liningepithelium on histopathologyPresence of allergic mucin containinga] eosinophilsb] charcot leyden crystalsc] fungal hyphaed] eosinophilic major basic protein
  7. 7. Clinical PresentationS/S nasal airway obstruction, allergicrhinities or chronic sinusitis, absent painGradual airway obstruction oftenneglected over a period of years untilcomplete obstructionUsually unilateral, Semisolid nasal crustFacial dysmorphia usually proptosis
  8. 8. Clinical Diagnosishigh index of suspicionNasal polyposis if unilateralYoung ageClassical radiological findingsThick sticky yellowish brown or greenmucusProptosis in a case of nasal polyposisS/s allergic rhinities not responding toantihistaminics, intranasal steroids
  9. 9. Bent and Kuhn diag. criteriaType 1 hypersensitivityNasal polypsChar. CT findingsPositive fungal stain or cultureAllergic mucin with fungal elements &no tissue invasion
  10. 10. Radiological FindingsHeterogenous areas of signal intensitiesCharacteristic serpigenous opacitiesExpansion, remodeling or thinning of involvedsinus wallsSometimes erosion of sinus wall mostly inorbitAsymmetrical involvement of sinusesOn MRI -Areas of reduced signal intensitieson T1 & signal void on T2 weighted images
  11. 11. Patient characteristicTotal - 24Age – 14 to 40Male:Female - 14:8Unilateral – 16Facial dysmorphia - 13Only proptosis - 10
  12. 12. TreatmentSurgery – Endoscopic sinus surgeryPrevention of recurrenceCorticosteroidsImmunotherapyAntifungals
  13. 13. Aims of surgeryConserevative but completeComplete extirpation of allergic mucin &fungal debrisPermanent drainage & ventilation ofsinus mucosa with MucosalpreservationPostoperative access to all sinuses
  14. 14. PreoperativeAntibioticSteroid for 7 daysPrednisolone 1mg/kg/dMethylprednisolone 16mg bd
  15. 15. Endoscopic Sinus SurgeryConservative surgeryRemoval in controlled fashion with theuse of powered instrumentsPreservation of mucosa ensures safetyof dura, periorbita
  16. 16. Advantages for surgery inAFRSPolyp serve as marker of diseaseExpansile behaviour increase access tothe diseaseEven the lateral most areas of frontalsinus can be accesed
  17. 17. Disadvantages for surgery inAFRSDistortion of local anatomyLoss of useful surgical landmarksBleeding can cause disorientationBone dissolution increases risk oforbital, intracranial penetration
  18. 18. Postoperative CareSaline nasal douchingWeekly clearance of crust & debrisendoscopicallySteroids for 3 weeks with taperingdosesRegular follow-up nasal/oral steroid ifrequired
  19. 19. RecidivismPolyps with fungal debris – 2 revisionsurgeryMucosal oedema & or polyps – 16steroids/ Intranasal steroidFungal debris in sinus - IrrigationNear normal – 6[No recurrence of s/s AFRS in any case]
  20. 20. Kupferbergs endoscopicmucosal stagingStage Endoscopic finding0 No mucosal edema orallergic mucin1 Mucosal edema/allergic mucin2 Polypoid edema3 Sinus polyps with fungal debris
  21. 21. ConclusionESS with powered instruments is crucialcomponent of therapyLong term control- How?Steroids - frequensy/durationImmunotherapyAntifungals
  22. 22. Thank You