Allergic fungal sinusitis: an otorhinolaryngologic perspective

Since the early 1980s, allergic fungal sinusitis (AFS) has been an increasingly recognized and diagnosed chronic health disorder. Although no single clinical definition has been agreed on, there are some well-accepted characteristics that have come to define this disease entity. Up to 10% of patients suffering from chronic rhinosinusitis may carry the diagnosis of AFS, and atopy is very common in these patients. The pathophysiological process that has been proposed involves the atopic host being exposed to the fungi, resulting in an inflammatory response (immunoglobulin E mediated), subsequent tissue edema, obstruction of sinus ostia, sinus stasis, further proliferation of fungus, increased antigenic exposure, etc., with a cycle that becomes self-perpetuating. Ultimately, the sinuses become filled with the characteristic allergic mucin that is the surgical hallmark of the disease, and the development of nasal and/or sinus polyposis also may ensue. Although the specific treatment of AFS generally is controversial, most otorhinolaryngologists would agree that surgical intervention is one universal mainstay of therapy. Minimally invasive but complete surgical exenteration of disease, with polypectomy and marsupialization of the involved sinuses, is a mandatory component of treatment. If complete surgery is achieved, the medical management of this challenging disease process will likely be more effective and fruitful.