Use of immunotherapy in previously treated patients with allergic fungal sinusitis.

OBJECTIVE: Sixty patients with a diagnosis of allergic fungal sinusitis were studied. The objective was to show whether, after initial surgical removal of allergic mucin and polyps, immunotherapy decreases re-operation rates and office visits that require medical intervention. STUDY DESIGN AND SETTING: Sixty patients with adequate follow-up for at least 1 year were evaluated: 24 patients who did not receive immunotherapy and 36 patients whose treatment included postoperative immunotherapy. RESULTS: The re-operation rates were 33.0% in those not receiving immunotherapy versus 11.1% in the treated group. Furthermore, the total number of postoperative office visits that required medical therapy decreased from 4.79 per patient to 3.17 with the addition of immunotherapy. CONCLUSION/SIGNIFICANCE: These results indicate that immunotherapy is a beneficial part of the overall treatment regimen for allergic fungal sinusitis.

Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution.

To achieve success in rhinoplasty, the plastic surgeon takes advantage of numerous intraoperative techniques designed to manipulate nasal soft tissue and the osseocartilaginous framework. Although the postoperative result may meet preoperative aesthetic goals, an element of nasal airway obstruction can persist from failure to acknowledge the role of inferior turbinates. Surgically responsive inferior turbinate hypertrophy is frequently not addressed secondary to inadequate history taking, incomplete physical examination, and/or surgeon reluctance to handle these sensitive structures. The goal of this article is to discuss the anatomy and physiology of the inferior turbinates, to present the role for inferior turbinate surgery during rhinoplasty, and to delineate the evolution of the current technique of submucosal resection of the inferior turbinates. Over the past 14 years, the senior author (R.J.R.) has performed inferior turbinates surgery on 648 patients as part of a rhinoplasty.

Allergic fungal rhinosinusitis: current theories and management strategies.

The combination of nasal polyposis, crust formation, and sinus cultures yielding Aspergillus was first noted in 1976 by Safirstein,1 who observed the clinical similarity that this constellation of findings shared with allergic bronchopulmonary Aspergillosis (ABPA). Eventually this disease came to be known as allergic fungal rhinosinusitis (AFS). As clinical evidence of AFS accumulated, controversy regarding its etiology, pathogenesis, natural history, and appropriate treatment naturally emerged. Despite past and current efforts, many of these controversies remain incompletely resolved, but continuing clinical study has illuminated some aspects of the disease and has led to an improved understanding of AFS and its treatment. Fungi associated with the development of AFS are ubiquitous and predominantly of the dematiaceous family. The eosinophilic host response to the presence of these fungi within the nose and paranasal sinuses gives rise to those clinical manifestations of the disease (nasal polyps, expansile mucocele formation, allergic fungal mucin, etc.). Exposure alone to these fungi, however, appears to be insufficient to initiate the disease. At the present time it is likely that initiation of the inflammatory cascade leading to AFS is a multifactorial event, requiring the simultaneous occurrence of such things as IgE-mediated sensitivity (atopy), specific T-cell HLA receptor expression, exposure to specific fungi, and aberration of local mucosal defense mechanisms. A variety of treatment plans for AFS have emerged, but the potential for recidivism remains well recognized, ranging from 10% to nearly 100%, suggesting the need for continued study of this disease and fueling present controversy. This article is intended to review current data and theories regarding the pathophysiology of AFS, as well as the role of various surgical and nonsurgical forms of therapy.

Characteristics of bony erosion in allergic fungal rhinosinusitis.

OBJECTIVES: Erosion of bone with or without extension of disease into adjacent anatomic spaces is observed among some patients with allergic fungal rhinosinusitis (AFRS). The objective of this report is to further define these findings as they relate to this disease. STUDY DESIGN: Retrospective chart review of 142 patients with AFRS diagnosed using the Bent-Kuhn criteria. All patients were treated at a single institution. RESULTS: Approximately 20% of patients with AFRS demonstrated bone erosion on CT scan. The ethmoid sinus was the most commonly eroded site. The orbit and anterior cranial fossa were the most common adjacent anatomic spaces to exhibit disease extension. Sinus expansion, not the specific organism identified, was associated with the presence of bone erosion. Surgical management with endoscopic techniques was successful for all patients without any major perioperative complications. CONCLUSION: Bone erosion can be related to AFR. Recognition of this possibility is important because bone erosion can be interpreted as an indication of invasive pathosis. In the presence of bone erosion or disease extension, endoscopic techniques can be used to surgically manage this disease.

Allergic fungal sinusitis: learning from our failures.

For more than five years, patients referred to the Department of Otolaryngology-Head and Neck Surgery at the University of Texas Southwestern Medical Center at Dallas with allergic fungal sinusitis (AFS) have been managed using a regimen combining surgery, perioperative corticosteroids, and immunotherapy for relevant antigens (fungal and non-fungal). The initial success of this program has been previously reported. Continued experience with this treatment plan, however, has yielded some cases of recurrence of AFS. Careful review of these cases implicate two major factors associated with treatment failure: (1) lack of compliance with immunotherapy, and (2) inadequate initial surgical extirpation of all allergic mucin. These cases and associated factors will be discussed.

Allergic fungal rhinosinusitis: surgical management.

Allergic fungal sinusitis is a newly characterized disease entity that has commanded a great deal of interest over the past 2 decades. As more information is gathered about its underlying etiology, clinical presentation, and response to therapy, the treatment of allergic fungal sinusitis is becoming more refined. Most current treatment protocols for allergic fungal sinusitis are based upon a combined surgical and medical approach. This article addresses pertinent surgical aspects as related to the management of allergic fungal sinusitis.

Geographic variation in allergic fungal rhinosinusitis.

Allergic fungal rhinosinusitis (AFRS) has a worldwide distribution. This survey of 20 otolaryngologic practices throughout the United States confirmed a variation in the frequency of AFRS relative to endoscopic sinus procedures performed for all other diagnoses. The highest incidence occurred in Memphis, Tennessee at 23%, with three other southern practices reporting a frequency of at least 10%. In the northern locations the frequency ranged from 0 to 4%. No correlation with mould counts was demonstrated, possibly because of incomplete mould data relative to most of the surgical locations.

Outcomes after discontinuing immunotherapy for allergic fungal sinusitis.

Although the treatment of allergic fungal sinusitis with specific immunotherapy after surgical intervention has proved successful, the question of what happens when such injections are discontinued remains unanswered. In this initial, admittedly small series, no recurrence has been noted in follow-up of 7 to 17 months.

Mold testing by RAST and skin test methods in patients with allergic fungal sinusitis.

RAST tests have traditionally been considered less sensitive than skin tests during investigation of atopy involving molds. This has been attributed to technical problems such as difficulty in binding the mold antigen to the carrier substrate. Ten patients with proven allergic fungal sinusitis were evaluated for sensitivity to 11 important molds by both RAST and dilutional intradermal testing. A predictable correlation between RAST and skin test scores was observed in many, but not all, cases. Most often this disparity was in the form of greater sensitivity indicated by skin testing than by RAST, sometimes differing by as many as 3 classes. The lack of concordance was not confined to testing for the fungi cultured from the sinuses, nor was it more or less pronounced in the case of dematiaceous fungi. The most likely causes for the disparity noted in this series are subtle differences in antigens used in skin test material and for RAST standards. Skin tests allow for evaluation of delayed and late-phase reactions, a measurement not possible by specific IgE testing with RAST. Delayed skin test reactions were not noted in this series of patients. An additional important finding was the sensitivity of patients with allergic fungal sinusitis to virtually every fungal antigen to which they were tested.

Allergic fungal sinusitis-induced visual loss.

In this report we review 56 adult and 26 pediatric patients who presented to our practice with pathologically confirmed allergic fungal sinusitis from 1989 to 1997. Of this group, three patients presented with visual loss and were treated with prompt surgical decompression followed by immunomodulation.

Immunotherapy for allergic fungal sinusitis: three years' experience.

Since August 1994, we have treated patients with histologically proven allergic fungal sinusitis with surgery followed by immunotherapy, employing fungal and nonfungal antigens to which hypersensitivity has been demonstrated. Our results continue to be encouraging. Not only have we encountered no indication that fungal immunotherapy has worsened these patients' condition or caused a recurrence of disease, we have confirmed dramatic improvement in these patients compared with the generally accepted course of this disease. Of 11 patients who have received immunotherapy for 1 to 3 years (mean 28 months), none has required regular or frequent treatment with a single brief course of systemic steroids, and only three are receiving topical nasal steroids. No repeat surgeries for recurrent allergic fungal sinusitis have been required in the treatment group. This combination of surgery and immunotherapy has continued to prove beneficial, and we urge others to consider this approach to therapy.

Treatment of allergic fungal sinusitis: a comparison trial of postoperative immunotherapy with specific fungal antigens.

OBJECTIVE: To determine the effect of immunotherapy (IT) with fungal antigens on clinical outcome in patients with allergic fungal sinusitis (AFS). STUDY DESIGN: Prospective case control. METHODS: In this comparison study, 22 patients meeting the diagnostic criteria of allergic fungal sinusitis (AFS) were evaluated after a mean of 33 months' therapy. All received similar treatment consisting of endoscopic sinus surgery, corticosteroids, and antibiotics as needed for complicating purulent sinusitis. Eleven patients received postoperative immunotherapy (IT) with fungal and nonfungal antigens to which sensitivity had been demonstrated, while the remaining 11 received no immunotherapy. RESULTS: The effect of IT was to significantly improve patient outcome as assessed objectively by an AFS endoscopic mucosal staging system (P < .001) and a sinusitis-specific quality-of-life scale, the Chronic Sinusitis Survey (P = .002). In addition, IT was shown to reduce reliance on systemic (P < .001) and topical nasal (P = .043) corticosteroid therapy to control disease. Follow-up was similar in the two groups and was not a determinant of differences in outcome (P = .7). CONCLUSIONS: Results from this study indicate that specific IT with fungal antigens improves patient outcome in AFS.

Comprehensive management of allergic fungal sinusitis.

In little more than a decade, allergic fungal sinusitis has gone from a medical curiosity to one of the more perplexing problems to challenge the otorhinolaryngologist. These patients are typically immunocompetent adolescents or young adults with pansinusitis (unilateral and bilateral) and polyposis, atopy, and characteristic radiographic findings. Allergic mucin contained within the sinuses demonstrates numerous eosinophils and Charcot-Leyden crystals, and fungal stains show the presence of noninvasive hyphae. Fungal cultures may or may not be positive. We have found the following approach to allergic fungal sinusitis to be most effective: 1) Adequate preoperative evaluation and medical preparation; 2) Meticulous exenterative surgery; 3) Closely supervised immunotherapy with relevant fungal and non-fungal antigens; 4) Medical management including topical and systemic corticosteroids as needed; 5) Irrigation and self-cleansing by the patient; and 6) Close clinical follow-up with endoscopically guided debridement when necessary.

Allergic fungal sinusitis: CT findings.

PURPOSE: To determine the computed tomographic (CT) findings in patients with allergic fungal sinusitis. MATERIALS AND METHODS: The authors retrospectively reviewed CT scans and surgical and histopathologic reports in 45 patients (27 male, 18 female; age range, 8-68 years) with allergic fungal sinusitis from multiple institutions. The median age (25 years) and demographics of the patients were determined. Two head and neck radiologists together evaluated the CT scans for the presence of intrasinus high-attenuation areas, extent of sinus involvement, bone expansion and thinning, bone erosion, and extension of disease into the adjacent soft tissues. RESULTS: Allergic fungal sinusitis was more common in male patients and in patients aged 20-30 years. All patients had increased intrasinus attenuation at non-contrast material-enhanced CT. Multiple sinus involvement occurred in 43 patients. Bilateral involvement was more common than unilateral disease. Forty-four patients had complete opacification of at least one of the involved sinuses; 43 of these patients had expansion of an involved sinus, 42 had remodeling and thinning of the bony sinus walls, and 41 had erosion of the sinus wall. CONCLUSION: Allergic fungal sinusitis is a distinct clinical entity with nonspecific symptoms that may be initially suggested by the CT findings. These findings should alert the clinician to the possibility of allergic fungal sinusitis and prompt other diagnostic studies to establish the diagnosis and treatment plan.

The middle cranial fossa approach in managing lesions of the temporomandibular joint.

The temporomandibular joint (TMS) lies at the skull base. Its bony roof forins part of the floor of the middle cranial fossa. It is bounded by the infratemporal fossa, external auditory canal, middle ear, and eustachian tube. When wide resection of tumors arising within the TMJ is necessary, skull base approaches permit complete resection with oncologically sound margins. Precise pathologic diagnosis can be difficult and extra care should be taken to ensure diagnostic accuracy. Outcomes are improved if attention and effort is directed to rehabilitation of the TMJ. Five such cases are presented and the literature is reviewed.

Disorders of the external auditory canal.

The normal anatomy and physiology of the external auditory canal is covered, followed by detailed descriptions of disorders and treatments of known and unknown etiology. Included are asteatosis, bacterial and fungal external otitis, bullous myringitis, allergic dermatitis, keratosis obturans, canal cholesteatoma, exostosis, osteoma, ceruminoma, basal and squamous cell carcinoma, and adenoma. A review of malignant external otitis is included with special emphasis on the expanding role of outpatient treatment and the use of oral antimicrobials.

Perilymphatic fistula.

Perilymph fistula is recognized as a clinically significant problem in certain patients. Owing to its lack of specific symptoms, diagnosis is difficult and depends upon a combination of historical data, physical findings, and test results. Early treatment is initiated in patients with overwhelming evidence of perilymph fistula, in order to ameliorate vestibular symptoms and preserve auditory function. Patients with subtle symptoms, however, should not be overlooked, because they will also benefit from the treatment of this disease.