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Allergic Fungal Rhinosinusitis
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Allergic Fungal Rhinosinusitis

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Allergic Fungal Rhinosinusitis Allergic Fungal Rhinosinusitis Presentation Transcript

  • Allergic Fungal Rhino sinusitisDr Sudhir HalikarConsultant & Head Dept of ENTPUNE, Maharashtra
  • AFRS is an allergic reaction toaerosolized environmentalfungi with allergic mucinousresponse in nonimmunocompromisedpatients.
  • Incidence5 – 10% patients of chronicrhinosinusitiesCommon in tropical countriesMore in young age2/3rdpatients reported h/o allergic rhinitis
  • 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
  • MycologyDematicious fungiBipolaries spiciferaAlternariaDreschleraCurvalariaHyaline mouldsAspergillus
  • AFRS PathologyAbsence of fungal mycelia in liningepithelium on histopathologyPresence of allergic mucin containinga] eosinophilsb] charcot leyden crystalsc] fungal hyphaed] eosinophilic major basic protein
  • 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
  • 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
  • Bent and Kuhn diag. criteriaType 1 hypersensitivityNasal polypsChar. CT findingsPositive fungal stain or cultureAllergic mucin with fungal elements &no tissue invasion
  • 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
  • Patient characteristicTotal - 24Age – 14 to 40Male:Female - 14:8Unilateral – 16Facial dysmorphia - 13Only proptosis - 10
  • TreatmentSurgery – Endoscopic sinus surgeryPrevention of recurrenceCorticosteroidsImmunotherapyAntifungals
  • Aims of surgeryConserevative but completeComplete extirpation of allergic mucin &fungal debrisPermanent drainage & ventilation ofsinus mucosa with MucosalpreservationPostoperative access to all sinuses
  • PreoperativeAntibioticSteroid for 7 daysPrednisolone 1mg/kg/dMethylprednisolone 16mg bd
  • Endoscopic Sinus SurgeryConservative surgeryRemoval in controlled fashion with theuse of powered instrumentsPreservation of mucosa ensures safetyof dura, periorbita
  • Advantages for surgery inAFRSPolyp serve as marker of diseaseExpansile behaviour increase access tothe diseaseEven the lateral most areas of frontalsinus can be accesed
  • Disadvantages for surgery inAFRSDistortion of local anatomyLoss of useful surgical landmarksBleeding can cause disorientationBone dissolution increases risk oforbital, intracranial penetration
  • Postoperative CareSaline nasal douchingWeekly clearance of crust & debrisendoscopicallySteroids for 3 weeks with taperingdosesRegular follow-up nasal/oral steroid ifrequired
  • 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]
  • Kupferbergs endoscopicmucosal stagingStage Endoscopic finding0 No mucosal edema orallergic mucin1 Mucosal edema/allergic mucin2 Polypoid edema3 Sinus polyps with fungal debris
  • ConclusionESS with powered instruments is crucialcomponent of therapyLong term control- How?Steroids - frequensy/durationImmunotherapyAntifungals
  • Thank You