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.

Inhalant allergy and Meniere's disease: Use of electrocochleography and intranasal allergen challenge as investigational tools.

INTRODUCTION: In an earlier study, we demonstrated the feasibility of using electrocochleography (ECoG) to document changes in inner ear function objectively after intranasal challenge of patients with inhalant allergy (with no prior immunotherapy) and Meniere's disease, using the antigen to which they were most sensitive. OBJECTIVE: We expand on this earlier study and continue to investigate the feasibility of this model in a subset of patients with inhalant allergy and Meniere's disease after immunotherapy. STUDY DESIGN: Prospective study of 11 patients identified with both Meniere's disease and inhalant allergy in the practices of 2 neurotologists at our institution. Patients underwent a baseline ECoG, followed by intranasal challenge with the allergen to which they were most sensitive. This was followed by a second ECoG. RESULTS: Six of 11 patients had at least 1 year of immunotherapy (group 1), and 5 of 11 had had 0 to 6 months of immunotherapy (group 2). Four of 6 group 1 patients had a >15% increase in SP/AP ratio after immunotherapy. In group 2, 2 patients increased the SP/AP in at least 1 ear. No patient with a normal ECoG experienced vestibular symptoms after allergen challenge, whereas 2 of group 1 and 2 of group 2 had vestibular symptoms with abnormal ECoGs. CONCLUSION: This protocol is a useful tool for investigating the relationship of inhalant allergy and Meniere's disease, but needs a larger group of patients and further study to draw valid statistical conclusions.

United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield.

BACKGROUND: This study was undertaken to determined the differences in injury patterns between soldiers equipped with modern body armor in an urban environment compared with the soldiers of the Vietnam War. METHODS: From July 1998 to March 1999, data were collected for a retrospective analysis on all combat casualties sustained by United States military forces in Mogadishu, Somalia, on October 3 and 4, 1993. This was the largest and most recent urban battle involving United States ground forces since the Vietnam War. RESULTS: There were 125 combat casualties. Casualty distribution was similar to that of Vietnam; 11% died on the battlefield, 3% died after reaching a medical facility, 47% were evacuated, and 39% returned to duty. The incidence of bullet wounds in Somalia was higher than in Vietnam (55% vs. 30%), whereas there were fewer fragment injuries (31% vs. 48%). Blunt injury (12%) and burns (2%) caused the remaining injuries in Somalia. Fatal penetrating injuries in Somalia compared with Vietnam included wounds to the head and face (36% vs. 35%), neck (7% vs. 8%), thorax (14% vs. 39%), abdomen (14% vs. 7%), thoracoabdominal (7% vs. 2%), pelvis (14% vs. 2%), and extremities (7% vs. 7%). No missiles penetrated the solid armor plate protecting the combatants' anterior chests and upper abdomens. Most fatal penetrating injuries were caused by missiles entering through areas not protected by body armor, such as the face, neck, pelvis, and groin. Three patients with penetrating abdominal wounds died from exsanguination, and two of these three died after damage-control procedures. CONCLUSION: The incidence of fatal head wounds was similar to that in Vietnam in spite of modern Kevlar helmets. Body armor reduced the number of fatal penetrating chest injuries. Penetrating wounds to the unprotected face, groin, and pelvis caused significant mortality. These data may be used to design improved body armor.

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 sinusitis: the role of immunotherapy.

The role of surgery and anti-inflammatory therapy (such as corticosteroids) in the management of allergic fungal sinusitis is accepted fairly universally. Although once thought to be contraindicated in the treatment of allergic fungal sinusitis, specific immunotherapy with fungal antigens has been shown to be extremely beneficial to these patients, when combined with surgery and adjunctive medical management. Recurrences have been prevented and systemic corticosteroid requirements virtually eliminated in an experience that now spans over 4 years.

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.

Electrocochleographic changes after intranasal allergen challenge: A possible diagnostic tool in patients with Meniere's disease.

Numerous observers have suggested a relationship between allergy and Meniere's disease, but objective proof has heretofore been limited. Using standard criteria, we studied a group of 7 patients with previously diagnosed Meniere's disease in whom significant allergy to 1 or more inhalants had also been diagnosed. Patients underwent a baseline electrocochleographic study followed by intranasal challenge with a carefully quantified amount of the allergen to which they were most sensitive. This was followed by a second electrocochleogram. Four of the 7 patients demonstrated at least a 15% increase in the summating potential/action potential ratio in 1 ear, associated with the production of subjective inner ear symptoms. We present this protocol as a potentially useful tool to further study whether inhalant allergy may be a causative factor in patients with Meniere's disease.

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.

Comparison of Multi-Test device skin testing and modified RAST results.

The initial purpose of this study was to determine the potential correlation between allergy test results obtained with the Multi-Test skin testing method and the radioallergosorbent test (RAST) blood test (used as a "standard"). Twenty patients with a history and physical examination findings suggestive of inhalant allergy underwent both a Multi-Test system screen (14 antigens plus histamine and glycerine controls) and RAST testing. The relationship between wheal size and Multi-Test system grade for each antigen and the corresponding RAST class was studied. The correlation between positive Multi-Test system and RAST results was poor, with an average agreement by antigen of 56.26% and overall agreement of 67.86%. However, the overall agreement between negative Multi-Test system results (< or =1+) and negative RAST results (< or =class 1) was 95.15%, with an average agreement by antigen of 83.99%. On the basis of results of this preliminary study, it appears that a negative Multi-Test system result indicates that significant inhalant allergy is unlikely, whereas a positive Multi-Test system result necessitates follow-up with more definitive testing by additional skin testing or RAST.

Geriatric rhinitis: what it is, and how to treat it.

In the nose, normal physiologic changes of aging include loss of nasal tip support, atrophy of mucus-producing mucosal glands, and decreased olfaction. These changes contribute to geriatric rhinitis, the symptoms of which are often attributed by the older patient to "allergies" or "sinus trouble." An understanding of these anatomic changes, linked with a thorough history and physical examination, allows the physician to properly manage geriatric rhinitis. Medical management most often involves liquifying--not drying--nasal secretions with oral and topical preparations. Conservative surgical treatment is occasionally indicated.

Allergy for rhinologists.

Our knowledge of the pathophysiology of allergy continues to grow, and with that understanding better treatment methods are being developed. An understanding of the appropriate diagnosis and treatment of allergy is mandatory for the physician who is treating patients with nasal and sinus disorders. Provision for this aspect of patient care will materially benefit such patients, although ignoring it places the physician at risk for repeated treatment failures.

Immunotherapy for allergic fungal sinusitis: the second year.

Since August 1994 we have followed a protocol of treating patients with histologically proven allergic fungal sinusitis with surgical extirpation of the involved sinuses, followed by immunotherapy using both fungal and nonfungal antigens to which hypersensitivity is demonstrated by in vitro and skin testing methods. Despite predictions to the contrary, we have encountered no evidence that these injections have worsened the condition of any patients. Rather, we have noted a marked decrease in nasal crusting in all patients, with a minimum amount of recurrent polypoid mucosa and a lessened or absent requirement for corticosteroids (systemic or topical). Two patients treated with immunotherapy required systemic corticosteroids and subsequent revision surgery for residual disease that was present before the start of immunotherapy, and they have done well since. Our experience indicates that the triad of adequate surgery, frequent follow-up and medical management, and immunotherapy with relevant fungal and nonfungal antigens represents an effective means of treating patients with allergic fungal sinusitis. Nevertheless, an even longer period of study will be necessary to provide the final answer regarding the role of immunotherapy in the treatment of allergic fungal sinusitis.