From the Guidelines
Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis that requires a combination of surgical and medical management to reduce morbidity, mortality, and improve quality of life, with the most recent evidence from 2020 suggesting that endoscopic sinus surgery and postoperative medical therapy with oral and topical corticosteroids are essential for treatment 1.
Diagnosis of AFRS
The diagnosis of AFRS is based on the presence of eosinophilic mucin with non-invasive fungal hyphae within the sinuses and a type I hypersensitivity to fungi, with the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 recommending that all five of the major criteria in the original Bent-Kuhn diagnostic criteria should be met to make the diagnosis 1. The diagnosis can be established by visualizing hyphae in mucus, which is supported by a positive anti-Aspergillus IgE serum antibody assay or skin-prick test 1.
Treatment of AFRS
The treatment of AFRS involves a combination of surgery and medical management, with the goal of reducing inflammation, removing fungal debris and polyps, and improving quality of life. Endoscopic sinus surgery is typically the first step to remove fungal debris and polyps, followed by postoperative medical therapy with oral corticosteroids, such as prednisone, and topical intranasal corticosteroids, such as fluticasone or budesonide 1. Antifungal agents are generally not effective, but may be considered in refractory cases 1. Saline irrigations and allergen immunotherapy may also be beneficial in some patients.
Key Principles of Treatment
The key principles of treatment for AFRS include:
- Surgical removal of fungal debris and polyps via endoscopic sinus surgery
- Postoperative medical therapy with oral and topical corticosteroids
- Use of saline irrigations to clear mucus and debris
- Consideration of allergen immunotherapy in patients with identified fungal allergies
- Regular follow-up with an otolaryngologist to monitor for recurrence
Importance of Recent Evidence
The most recent evidence from 2020 suggests that the treatment of AFRS should focus on reducing inflammation and removing fungal debris and polyps, with a combination of surgical and medical management 1. This approach is supported by the European Position Paper on Rhinosinusitis and Nasal Polyps 2020, which recommends a comprehensive treatment plan that includes endoscopic sinus surgery, postoperative medical therapy, and regular follow-up.
From the Research
Diagnosis of Allergic Fungal Rhinosinusitis (AFRS)
- The diagnosis of AFRS depends on history, CT scanning, histopathology, mycologic and immunologic monitoring 2, 3
- Characteristic computed tomographic findings, such as serpiginous or patchy increased attenuation within the completely opacified sinuses, may have predictive value for a final diagnosis of AFRS 2, 4
- Type 1 hypersensitivity to fungal antigens helps to distinguish AFRS from other forms of eosinophilic mucin chronic rhinosinusitis 4
- Elevated levels of fungal-specific IgE and IgG3 are consistent findings in patients with AFRS 4
Treatment of Allergic Fungal Rhinosinusitis (AFRS)
- Comprehensive treatment with endoscopic sinus surgery, steroids, and saline irrigations with antifungal drugs is an effective method 2, 5, 3
- Postoperative systemic and standard topical nasal steroids are recommended in the medical management of AFRS 6
- Nonstandard topical nasal steroids, oral antifungals, and immunotherapy are options in cases of refractory AFRS 6
- Antifungal treatment is still considered a treatment option, but further study is needed 4
- The use of systemic steroids is recommended in the treatment of AFRS 5
- Surgical intervention is necessary to remove the fungal elements and to restore sinus drainage and aeration 2, 5, 3