Comprehensive management of allergic fungal sinusitis

In little more than a decade, allergic fungal sinusitis has gone from a medical curiosity to one of the more perplexing problems to challenge the otorhinolaryngologist. These patients are typically immunocompetent adolescents or young adults with pansinusitis (unilateral and bilateral) and polyposis, atopy, and characteristic radiographic findings. Allergic mucin contained within the sinuses demonstrates numerous eosinophils and Charcot-Leyden crystals, and fungal stains show the presence of noninvasive hyphae. Fungal cultures may or may not be positive. We have found the following approach to allergic fungal sinusitis to be most effective: 1) Adequate preoperative evaluation and medical preparation; 2) Meticulous exenterative surgery; 3) Closely supervised immunotherapy with relevant fungal and non-fungal antigens; 4) Medical management including topical and systemic corticosteroids as needed; 5) Irrigation and self-cleansing by the patient; and 6) Close clinical follow-up with endoscopically guided debridement when necessary.