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Allergic Fungal Rhinosinusitis
- 1. Allergic Fungal Rhino sinusitis Dr Sudhir Halikar Consultant & Head Dept of ENT PUNE, Maharashtra
- 2. AFRS is an allergic reaction to aerosolized environmental fungi with allergic mucinous response in non immunocompromised patients.
- 3. Incidence 5 – 10% patients of chronic rhinosinusities Common in tropical countries More in young age 2/3rd patients reported h/o allergic rhinitis
- 4. History Decades ago fungal infection of nose is considered as deadly fungal disease In 1976 Safirstein noted polyposis , crust formation & aspergillus in culture similar to Allergic bronchopulmonary aspergillosis[ABPA] In 1989 Robson coined the term Allergic Fungal Sinusitis
- 5. Mycology Dematicious fungi Bipolaries spicifera Alternaria Dreschlera Curvalaria Hyaline moulds Aspergillus
- 6. AFRS Pathology Absence of fungal mycelia in lining epithelium on histopathology Presence of allergic mucin containing a] eosinophils b] charcot leyden crystals c] fungal hyphae d] eosinophilic major basic protein
- 7. Clinical Presentation S/S nasal airway obstruction, allergic rhinities or chronic sinusitis, absent pain Gradual airway obstruction often neglected over a period of years until complete obstruction Usually unilateral, Semisolid nasal crust Facial dysmorphia usually proptosis
- 11. Clinical Diagnosis high index of suspicion Nasal polyposis if unilateral Young age Classical radiological findings Thick sticky yellowish brown or green mucus Proptosis in a case of nasal polyposis S/s allergic rhinities not responding to antihistaminics, intranasal steroids
- 12. Bent and Kuhn diag. criteria Type 1 hypersensitivity Nasal polyps Char. CT findings Positive fungal stain or culture Allergic mucin with fungal elements & no tissue invasion
- 13. Radiological Findings Heterogenous areas of signal intensities Characteristic serpigenous opacities Expansion, remodeling or thinning of involved sinus walls Sometimes erosion of sinus wall mostly in orbit Asymmetrical involvement of sinuses On MRI -Areas of reduced signal intensities on T1 & signal void on T2 weighted images
- 18. Patient characteristic Total - 24 Age – 14 to 40 Male:Female - 14:8 Unilateral – 16 Facial dysmorphia - 13 Only proptosis - 10
- 19. Treatment Surgery – Endoscopic sinus surgery Prevention of recurrence Corticosteroids Immunotherapy Antifungals
- 20. Aims of surgery Conserevative but complete Complete extirpation of allergic mucin & fungal debris Permanent drainage & ventilation of sinus mucosa with Mucosal preservation Postoperative access to all sinuses
- 21. Preoperative Antibiotic Steroid for 7 days Prednisolone 1mg/kg/d Methylprednisolone 16mg bd
- 22. Endoscopic Sinus Surgery Conservative surgery Removal in controlled fashion with the use of powered instruments Preservation of mucosa ensures safety of dura, periorbita
- 27. Advantages for surgery in AFRS Polyp serve as marker of disease Expansile behaviour increase access to the disease Even the lateral most areas of frontal sinus can be accesed
- 28. Disadvantages for surgery in AFRS Distortion of local anatomy Loss of useful surgical landmarks Bleeding can cause disorientation Bone dissolution increases risk of orbital, intracranial penetration
- 30. Postoperative Care Saline nasal douching Weekly clearance of crust & debris endoscopically Steroids for 3 weeks with tapering doses Regular follow-up nasal/oral steroid if required
- 32. Recidivism Polyps with fungal debris – 2 revision surgery Mucosal oedema & or polyps – 16 steroids/ Intranasal steroid Fungal debris in sinus - Irrigation Near normal – 6 [No recurrence of s/s AFRS in any case]
- 33. Kupferbergs endoscopic mucosal staging Stage Endoscopic finding 0 No mucosal edema or allergic mucin 1 Mucosal edema/allergic mucin 2 Polypoid edema 3 Sinus polyps with fungal debris
- 38. Conclusion ESS with powered instruments is crucial component of therapy Long term control- How? Steroids - frequensy/duration Immunotherapy Antifungals
- 39. Thank You