Allergic Fungal Sinusitis Allergic Fungal Sinusitis William - - PowerPoint PPT Presentation
Allergic Fungal Sinusitis Allergic Fungal Sinusitis William Reisacher, MD FACS FAAOA William Reisacher, MD FACS FAAOA Assistant Professor Assistant Professor Weill Cornell Medical College Weill Cornell Medical College NewYork- -Presbyterian
William Reisacher, MD FACS FAAOA William Reisacher, MD FACS FAAOA Assistant Professor Assistant Professor Weill Cornell Medical College Weill Cornell Medical College NewYork NewYork-
Presbyterian Hospital
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CRS w/o NP
AFS
CRS w NP
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– – Type I hypersensitivity Type I hypersensitivity – – Nasal polyps Nasal polyps – – Characteristic radiologic findings Characteristic radiologic findings – – Eosinophilic Eosinophilic mucus without fungal invasion into sinus mucus without fungal invasion into sinus tissue tissue – – Positive fungal stain of sinus contents removed at Positive fungal stain of sinus contents removed at surgery surgery
Young, atopic and immunocompetent immunocompetent
Mean age of presentation is 28.9
Lower socioeconomic status
More common in southeastern United States7
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10% of all patient undergoing surgery for CRS7
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Present in 51% of patients in Northern India with CRS10
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Wise et al. – – African Americans with AFS presented with African Americans with AFS presented with mean age 11.7 years younger than Caucasians mean age 11.7 years younger than Caucasians11
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Ghegan et al. et al. – – African American males were 15x more African American males were 15x more likely to have bone erosion than Caucasians and African likely to have bone erosion than Caucasians and African American females combined American females combined12
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CRS with nasal polyposis polyposis
EMCRS
Invasive fungal sinusitis
Mycetoma ( (“ “Fungus ball Fungus ball” ”) )
Antrochoanal polyp polyp
Neoplasm
– – Inverting Inverting papilloma papilloma – – Carcinoma Carcinoma – – Nasolacrimal Nasolacrimal duct cyst duct cyst – – Glioma Glioma, , dermoid dermoid lesions, lesions, encephaloceles encephaloceles
Inflammatory / Autoimmune
– – Wegener Wegener’ ’s s granulomatosis granulomatosis – – Sarcoidosis Sarcoidosis
Polypoid mucosal changes mucosal changes
CT scan T1 - MRI
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Prior radical procedures replaced by complete, but conservative endoscopic surgery. conservative endoscopic surgery.
Follow the polyps to the mucin mucin
Image-
guidance if available
Don’ ’t forget to send the t forget to send the mucin mucin for fungal staining for fungal staining
Post-
Kupferberg staging system staging system
– – Stage 0: NED Stage 0: NED – – Stage 1: Edematous mucosa/allergic Stage 1: Edematous mucosa/allergic mucin mucin – – Stage 2: Stage 2: Polypoid Polypoid mucosa/allergic mucosa/allergic mucin mucin – – Stage 3: Polyps and fungal debris Stage 3: Polyps and fungal debris
Need for revision surgery is about 30% 14
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– – 60 patient with AFS 60 patient with AFS – – 24 patients, no IT. 36 patients, IT 24 patients, no IT. 36 patients, IT – – Average follow Average follow-
up was 48.5 months – – Significant reduction of office visits Significant reduction of office visits – – Decrease in need for re Decrease in need for re-
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– – Alternaria Alternaria – – Bipolaris Bipolaris – – Curvularia Curvularia – – Helminthosporium Helminthosporium – – Fusarium Fusarium
Ponikau et al. from Mayo Clinic suggested that NP may arise from et al. from Mayo Clinic suggested that NP may arise from immune hyper responsiveness to fungi that commonly colonize the immune hyper responsiveness to fungi that commonly colonize the nose of patients with CRS nose of patients with CRS17
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Gosepath et al. demonstrated et al. demonstrated Alternaria Alternaria DNA in 100% of surgical DNA in 100% of surgical polyp specimens from CRS patients polyp specimens from CRS patients18
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Sabirov et al. studied the role of local et al. studied the role of local IgE IgE specific for Alternaria specific for Alternaria19
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– – CRS w NP (N= 21) vs. CRS w/o NP (N= 13) and healthy controls (N= 8) CRS w NP (N= 21) vs. CRS w/o NP (N= 13) and healthy controls (N= 8) – – Serum levels of Serum levels of Alternaria Alternaria-
specific IgE IgE were no different between were no different between groups groups – – Alternaria Alternaria-
specific IgE IgE in polyps was significantly higher than in the in polyps was significantly higher than in the nasal tissues of the other two groups nasal tissues of the other two groups
An association was present between alternaria alternaria-
specific IgE IgE and and increased ECP and increased ECP and eosinophil eosinophil levels in patients with nasal polyps levels in patients with nasal polyps19
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Stewart and Hunsaker Hunsaker, 2002 , 200220
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– – 13 AFS, 11 AFS 13 AFS, 11 AFS-
like, 27 non-
AFS polypoid polypoid CRS CRS – – 9 mold RAST panel 9 mold RAST panel – – Elevated Elevated IgG IgG in all groups in all groups – – Elevated Elevated IgE IgE in AFS group to average of 5 molds vs. 0.1 in the in AFS group to average of 5 molds vs. 0.1 in the AFS AFS-
like group
Wise, et al., 200821
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– – Sinus mucosa homogenates from AFS (11), Sinus mucosa homogenates from AFS (11), CRSsNP CRSsNP (8) and non (8) and non-
CRS patients (9) – – ImmunoCAP ImmunoCAP for 14 common antigens for 14 common antigens – – AFS group had significantly higher levels of AFS group had significantly higher levels of IgE IgE for for Cladosporium Cladosporium, , Aspergillus Aspergillus, Timothy grass, red maple, cockroach, , Timothy grass, red maple, cockroach, ragweed and cocklebur ragweed and cocklebur
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– – Fungus not identified Fungus not identified histologically histologically – – Higher incidence of asthma, ASA sensitivity Higher incidence of asthma, ASA sensitivity – – Lower incidence of allergies Lower incidence of allergies – – Always bilateral Always bilateral
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– – Comparison of AFRS with non Comparison of AFRS with non-
AFRS EMCRS (negative for allergy and no fungus identified in the for allergy and no fungus identified in the mucin mucin) ) – – 17/24 AFRS had fungal specific 17/24 AFRS had fungal specific IgE IgE in in mucin mucin compared to 20% in non compared to 20% in non-
AFRS EMCRS – – Possibly a local Possibly a local IgE IgE-
mediated immune response
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