What is the management of Allergic Fungal Rhinosinusitis (AFRS)?

Management of Allergic Fungal Rhinosinusitis

Surgery is the cornerstone of AFRS treatment and should be performed first, followed by postoperative oral corticosteroids for 6 months to reduce recurrence, with intranasal corticosteroids for long-term maintenance. 1, 2

Primary Treatment: Surgical Intervention

Endoscopic sinus surgery (ESS) is mandatory as first-line treatment for AFRS. 1 Medical therapy alone without surgical intervention is ineffective for long-term management and should not be attempted. 1, 2

Surgical Goals and Technique

• Complete surgical debridement of all involved sinuses to remove fungal material and eosinophilic mucin 1, 2
• Incomplete removal of allergic mucin directly contributes to disease recurrence and need for revision surgery 1
• Surgery provides wider sinus access for postoperative surveillance, clinical debridement, and topical medication application 1, 2
• If contralateral sinus shows radiologic inflammation, it should be surgically addressed even if minimally symptomatic (reduces contralateral involvement from 30% to much lower rates with postoperative steroids) 1

Complications Requiring Surgery

• Skull base erosions with cranial neuropathies require surgical intervention as the only successful treatment (spontaneous resolution does not occur) 1
• Proptosis from orbital involvement resolves with sinus surgery alone; orbital reconstruction is not necessary 1

Postoperative Medical Management

Oral Corticosteroids (Essential)

Extended-duration oral corticosteroids (6 months) significantly reduce recurrence compared to shorter courses. 1, 2

Recommended regimen based on highest quality RCT evidence: 1, 2

• Prednisolone 1 mg/kg/day for 1 week preoperatively
• 0.5 mg/kg/day for 4 weeks postoperatively
• 0.4 mg/kg/day for next 4 weeks
• Taper to 0.2 mg/kg/day for 2 months
• Taper to 0.1 mg/kg/day for final 2 months

Evidence supporting this approach:

• 6-month corticosteroid regimen: 10% recurrence rate 1
• 2-month corticosteroid regimen: 30% recurrence rate 1
• No postoperative corticosteroids: 50% recurrence rate at 2 years 1
• RCT data shows all patients on 12-week oral prednisolone were asymptomatic at follow-up versus only 1 of 12 on placebo 1

Intranasal Corticosteroids (Maintenance)

• Intranasal corticosteroids are beneficial, safe, and well-tolerated for long-term AFRS management 2
• Non-standard delivery methods (nebulization) are more effective than standard nasal sprays 2
• Continue indefinitely for maintenance after completing oral corticosteroid taper 2

Antifungal Therapy (Not Routinely Recommended)

Antifungal agents should not be routinely used in AFRS management. 1

• Meta-analysis and Cochrane review of topical and systemic antifungal therapies in CRS patients failed to demonstrate benefit 1
• Oral antifungals do not improve symptoms in AFRS 1
• Evidence for oral antifungals reducing recurrence is mixed and meta-analysis is negative 1
• Topical antifungals have minimal evidence of benefit 1

Emerging Biologic Therapies (Refractory Cases Only)

For AFRS refractory to surgery and oral corticosteroids, consider biologic agents targeting type 2 inflammation. 1, 3, 4

• Omalizumab (anti-IgE): Case series showed significant SNOT-22 reduction and 60% reduction in endoscopic inflammation scores over 7 months 1
• Dupilumab: Case reports demonstrate excellent control in recalcitrant AFRS with multiple failed surgeries 3, 4
• Mepolizumab: Shows promise but limited AFRS-specific data 4
• These agents reduce corticosteroid dependence and improve quality of life 1, 3

Therapies Without Evidence of Benefit

• Manuka honey topically does not improve outcomes 1
• Leukotriene modifiers have only single case study support 1
• Immunotherapy data remains unclear and is not recommended in current guidelines 4, 5

Critical Pitfalls to Avoid

Do not attempt medical management alone without surgery - this approach universally fails in all but the mildest cases. 1, 2

Do not use short-course oral corticosteroids - 2-month regimens have 3-fold higher recurrence than 6-month regimens (30% vs 10%). 1, 2

Monitor for corticosteroid side effects during extended therapy: 1

• Weight gain (universal in RCT data)
• Cushingoid features (occurred in 5 of 12 patients in RCT)
• Steroid-induced diabetes (occurred in 1 of 12 patients in RCT)
• Consider pretreatment tuberculosis screening, ophthalmologic evaluation, and bone mineral density assessment for protracted courses 1

Do not perform balloon sinuplasty for AFRS - this condition requires full exposure and removal of diseased tissue, not simple dilation. 6

Long-Term Follow-Up

• Recurrence rates after surgery range from 10% to 100% depending on postoperative medical management 1
• Regular endoscopic surveillance is essential to detect early recurrence 1, 2
• Early intervention for recurrence prevents need for extensive revision surgery 1