1. Allergic Fungal Rhino sinusitis
Dr Sudhir Halikar
Consultant & Head Dept of ENT
PUNE, Maharashtra

2. AFRS is an allergic reaction to
aerosolized environmental
fungi with allergic mucinous
response in non
immunocompromised
patients.

3. Incidence
5 – 10% patients of chronic
rhinosinusities
Common in tropical countries
More in young age
2/3rd
patients reported h/o allergic rhinitis

4. History
Decades ago fungal infection of nose is
considered as deadly fungal disease
In 1976 Safirstein noted polyposis ,
crust formation & aspergillus in culture
similar to Allergic bronchopulmonary
aspergillosis[ABPA]
In 1989 Robson coined the term
Allergic Fungal Sinusitis

5. Mycology
Dematicious fungi
Bipolaries spicifera
Alternaria
Dreschlera
Curvalaria
Hyaline moulds
Aspergillus

6. AFRS Pathology
Absence of fungal mycelia in lining
epithelium on histopathology
Presence of allergic mucin containing
a] eosinophils
b] charcot leyden crystals
c] fungal hyphae
d] eosinophilic major basic protein

7. Clinical Presentation
S/S nasal airway obstruction, allergic
rhinities or chronic sinusitis, absent pain
Gradual airway obstruction often
neglected over a period of years until
complete obstruction
Usually unilateral, Semisolid nasal crust
Facial dysmorphia usually proptosis

11. Clinical Diagnosis
high index of suspicion
Nasal polyposis if unilateral
Young age
Classical radiological findings
Thick sticky yellowish brown or green
mucus
Proptosis in a case of nasal polyposis
S/s allergic rhinities not responding to
antihistaminics, intranasal steroids

12. Bent and Kuhn diag. criteria
Type 1 hypersensitivity
Nasal polyps
Char. CT findings
Positive fungal stain or culture
Allergic mucin with fungal elements &
no tissue invasion

13. Radiological Findings
Heterogenous areas of signal intensities
Characteristic serpigenous opacities
Expansion, remodeling or thinning of involved
sinus walls
Sometimes erosion of sinus wall mostly in
orbit
Asymmetrical involvement of sinuses
On MRI -Areas of reduced signal intensities
on T1 & signal void on T2 weighted images

18. Patient characteristic
Total - 24
Age – 14 to 40
Male:Female - 14:8
Unilateral – 16
Facial dysmorphia - 13
Only proptosis - 10

19. Treatment
Surgery – Endoscopic sinus surgery
Prevention of recurrence
Corticosteroids
Immunotherapy
Antifungals

20. Aims of surgery
Conserevative but complete
Complete extirpation of allergic mucin &
fungal debris
Permanent drainage & ventilation of
sinus mucosa with Mucosal
preservation
Postoperative access to all sinuses

21. Preoperative
Antibiotic
Steroid for 7 days
Prednisolone 1mg/kg/d
Methylprednisolone 16mg bd

22. Endoscopic Sinus Surgery
Conservative surgery
Removal in controlled fashion with the
use of powered instruments
Preservation of mucosa ensures safety
of dura, periorbita

27. Advantages for surgery in
AFRS
Polyp serve as marker of disease
Expansile behaviour increase access to
the disease
Even the lateral most areas of frontal
sinus can be accesed

28. Disadvantages for surgery in
AFRS
Distortion of local anatomy
Loss of useful surgical landmarks
Bleeding can cause disorientation
Bone dissolution increases risk of
orbital, intracranial penetration

30. Postoperative Care
Saline nasal douching
Weekly clearance of crust & debris
endoscopically
Steroids for 3 weeks with tapering
doses
Regular follow-up nasal/oral steroid if
required

32. Recidivism
Polyps with fungal debris – 2 revision
surgery
Mucosal oedema & or polyps – 16
steroids/ Intranasal steroid
Fungal debris in sinus - Irrigation
Near normal – 6
[No recurrence of s/s AFRS in any case]

33. Kupferbergs endoscopic
mucosal staging
Stage Endoscopic finding
0 No mucosal edema or
allergic mucin
1 Mucosal edema/allergic mucin
2 Polypoid edema
3 Sinus polyps with fungal debris

38. Conclusion
ESS with powered instruments is crucial
component of therapy
Long term control- How?
Steroids - frequensy/duration
Immunotherapy
Antifungals

39. Thank You