Management of Allergic Fungal Rhinosinusitis (AFRS) According to EPOS 2020 Guidelines
Fundamental Treatment Approach
Surgery is the cornerstone of AFRS management, followed by appropriate medical therapy to prevent recurrence. 1 Surgical intervention is essential as the first-line treatment for AFRS, as medical therapy alone is usually ineffective in providing long-term symptom relief.
Surgical Management
Primary Surgical Intervention
- Complete surgical debridement of all involved sinuses is necessary to:
- Remove antigenic stimulation
- Provide wider access for surveillance
- Allow application of topical medications
- Remove all fungal and eosinophilic mucin
Surgical Considerations
- Incomplete removal of fungal and eosinophilic mucin contributes to disease recurrence 1
- Recurrence rates after surgery range from 10% to 100% 1
- The contralateral sinus should be treated if there are radiological signs of inflammation 1
- For skull base erosions with cranial neuropathies, surgery is the only successful intervention 1
- In cases of proptosis, sinus surgery alone is usually sufficient; orbital reconstruction is not necessary 1
Post-Surgical Medical Management
Systemic Corticosteroids
- Postoperative systemic corticosteroids significantly reduce recurrence rates and improve outcomes 1
- Evidence from RCTs shows that:
- 6-month postoperative corticosteroid regimen is associated with less recurrence (10%) compared to 2-month regimen (30%) 1
- Oral prednisolone (50mg daily for 6 weeks, then 6-week taper) results in significantly better symptom scores than placebo 1
- Patients without postoperative corticosteroids have higher recurrence rates (50%) compared to those receiving corticosteroids (15.2%) 1
Recommended Corticosteroid Regimens
- Long-term regimen: Prednisolone 1mg/kg/day for 1 week preoperatively and 0.5mg/kg/day for 4 weeks postoperatively, then tapered to 0.4mg/kg/day for 4 weeks, 0.2mg/kg/day for 2 months, and 0.1mg/kg/day for the last 2 months 1
- Short-term regimen: Prednisolone 1mg/kg/day for 1 week preoperatively and 0.5mg/kg/day for 4 weeks postoperatively 1
Topical Corticosteroids
- Intranasal corticosteroids are beneficial in controlling AFRS 1
- Nebulized budesonide is more effective than standard intranasal corticosteroid sprays in preventing recurrence 1
Antifungal Therapy
- Oral antifungals may reduce inflammation and recurrence in AFRS, but evidence is limited 1
- Meta-analyses of topical and systemic antifungal therapies have failed to demonstrate consistent benefit 1
- If used, itraconazole (100-200mg twice daily) is the most commonly studied agent 1
Other Medical Interventions
- Manuka honey topically does not improve outcomes (Level 1b evidence) 1
- Omalizumab (anti-IgE) may improve outcomes in AFRS, especially in patients with concomitant asthma 1
- Leukotriene antagonists have been reported with benefit in single case studies 1
- Emerging biologics (dupilumab, mepolizumab) show promise for CRSwNP but need specific studies in AFRS 2
Monitoring and Follow-up
- Regular endoscopic surveillance is essential to detect early recurrence
- Monitor for:
- Recurrence of polyps
- Accumulation of allergic mucin
- Mucosal inflammation
- Adjust medical therapy based on endoscopic findings
Treatment Algorithm for AFRS
Diagnosis confirmation:
- Characteristic CT findings (hyperdensities in sinuses with expansion/erosion of bony walls)
- Presence of allergic "peanut-butter-like" mucin
- Type I hypersensitivity to fungi
Initial management:
- Consider preoperative systemic corticosteroids (prednisolone 1mg/kg/day for 1 week) to reduce inflammation
- Complete surgical debridement of all involved sinuses
Immediate postoperative care:
- Systemic corticosteroids (prednisolone 0.5mg/kg/day for 4 weeks)
- Intranasal corticosteroids (preferably nebulized budesonide)
- Saline irrigations
Long-term management:
- Gradually taper systemic corticosteroids over 6 months
- Continue intranasal corticosteroids indefinitely
- Consider oral antifungals in refractory cases
- Regular endoscopic surveillance
For recurrence or flare-ups:
- Short course of systemic corticosteroids
- Consider biologics (omalizumab) in patients with concomitant asthma
- Revision surgery if medical management fails
Common Pitfalls to Avoid
- Relying solely on medical therapy without surgical intervention
- Inadequate surgical debridement of fungal and eosinophilic mucin
- Premature discontinuation of postoperative corticosteroids
- Overreliance on antifungal agents despite limited evidence
- Failure to monitor for recurrence with regular endoscopic examinations
- Neglecting to address concomitant conditions (asthma, allergic rhinitis)
AFRS management requires a long-term approach with surgery as the foundation, followed by appropriate medical therapy to prevent recurrence and maintain disease control.