Management Recommendations for Allergic Fungal Rhinosinusitis (AFRS) According to EPOS2020
According to EPOS2020, the foundation of AFRS treatment is surgical intervention, as medical therapy alone is usually ineffective in alleviating symptoms, and surgical intervention combined with medical therapy leads to improved clinical outcomes. 1
Definition and Characteristics of AFRS
- AFRS is a subset of polypoid chronic rhinosinusitis characterized by the presence of eosinophilic mucin with non-invasive fungal hyphae within the sinuses 1
- AFRS is primarily considered an IgE-mediated mucosal hypersensitivity directed against fungal antigens deposited on sinus mucosa 1
- Key defining features include: 1) fungi never invade the sinus tissue, and 2) mucin is the product of an allergic hypersensitivity reaction to fungi 1
- Imaging shows densely packed hyperdensities in the sinuses with expansion and erosion of the bony walls 1
Surgical Management
- Endoscopic sinus surgery (ESS) is the primary treatment modality for AFRS 1
- Surgery provides debridement of involved sinuses, removing the antigenic stimulation 1
- Surgical intervention also provides wider access for surveillance, clinical debridement, and application of topical medications 1
- The extent of surgical resection is guided by preoperative imaging and tissue appearance during surgery 1
Postoperative Medical Management
Systemic Corticosteroids
- Oral corticosteroids have demonstrated significant benefit in the postoperative setting 1
- Postoperative systemic corticosteroids improve short-term outcomes (Level 1b evidence) 1
- Longer-term use (6 months) of oral corticosteroids is associated with less recurrence compared to shorter regimens (2 months) 1
- In a randomized controlled trial, patients receiving oral prednisolone (50mg daily for 6 weeks, followed by a 6-week taper) showed significantly improved symptom scores compared to placebo 1
Topical Corticosteroids
- Intranasal corticosteroids (INCS) are beneficial, safe, and well-tolerated in AFRS management 1
- Non-standard delivery methods (nebulization) appear more effective than standard nasal sprays (Level 1b evidence) 1
- INCS of any type may be useful in controlling AFRS (Level 3b evidence) 1
Antifungal Therapy
- Evidence for oral antifungals in AFRS management is mixed 1
- Topical antifungals have shown some benefit in preventing recurrence in some studies 1, 2
- One study showed that fluconazole nasal spray reduced recurrence rates to 10% compared to 75% in controls 2
- However, EPOS2020 does not strongly recommend routine use of antifungals due to limited evidence 1
Immunotherapy
- Allergen immunotherapy may be considered as an option in refractory cases 3
- However, there is limited evidence supporting its routine use in AFRS management 3
Emerging Therapies
- Biological agents such as Dupilumab are being investigated for refractory AFRS cases 4, 5
- These are primarily being prescribed for associated respiratory conditions rather than specifically for sinus disease 6
Common Pitfalls and Caveats
- Medical therapy alone without surgical intervention is generally ineffective for long-term management 1
- Recurrence rates remain high despite various management strategies 2
- Prolonged systemic corticosteroid use carries significant side effects including weight gain, Cushingoid features, and potential for steroid-induced diabetes 1
- Regular follow-up is essential for early detection of recurrence or disease flare-ups 6
Recommended Management Algorithm
- Surgical intervention (ESS) as primary treatment to remove fungal load and antigenic material 1
- Postoperative systemic corticosteroids (e.g., prednisolone 1mg/kg/day tapered over several months) 1
- Concurrent intranasal corticosteroids for maintenance therapy 1
- Consider non-standard corticosteroid delivery methods (nebulization) for better efficacy 1
- For refractory cases, consider oral antifungals or immunotherapy as adjunctive options 3
- Regular follow-up with endoscopic examination to monitor for recurrence 6