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Transcript of AFRS: Current Approaches to Postoperative Management Bradley F. Marple, MD Professor Dept. of...
AFRS: Current AFRS: Current Approaches to Approaches to Postoperative Postoperative ManagementManagement
Bradley F. Marple, MDBradley F. Marple, MD
ProfessorProfessor
Dept. of OtolaryngologyDept. of OtolaryngologyUniv. of Texas Southwestern at DallasUniv. of Texas Southwestern at Dallas
Potential Role for Potential Role for Fungus in CRSFungus in CRS
Allergic Fungal RhinosinusitisAllergic Fungal Rhinosinusitis
SaprophyteSaprophyte EFRSEFRS
•Fungus•Fungal allergy•Invasive Fungus
•Fulminant•Indolent•Granulomatous
•Non-invasive fungus•Mycetoma•Saprophytic growth•AFRS•EFRS
•Fungus•Fungal allergy•Invasive Fungus
•Fulminant•Indolent•Granulomatous
•Non-invasive fungus•Mycetoma•Saprophytic growth•AFRS•EFRS
Marple, Laryngoscope 2001;111:1006-19.Marple, Laryngoscope 2001;111:1006-19.
Clinical Observations Concerning AFRS
Clinical Observations Concerning AFRS
Radiographic Radiographic Characteristics:Characteristics:Bone ErosionBone Erosion
Radiographic Radiographic Characteristics:Characteristics:Bone ErosionBone Erosion
CTCT11
Allergic mucin mucoceleAllergic mucin mucocele Associated obstructive Associated obstructive
sinusitissinusitis Heterogeneous Heterogeneous
appearanceappearance33
CaCa Chelated Fe, MnChelated Fe, Mn
MukherjiMukherji11
Reviewed 45 AFRS CTsReviewed 45 AFRS CTs Bone erosion - 20%Bone erosion - 20%
Nussenbaum, MarpleNussenbaum, Marple22
Reviewed 142 AFRS CTsReviewed 142 AFRS CTs Bone erosion - 20%Bone erosion - 20% Histology - 0/142 Histology - 0/142
demonstrated invasiondemonstrated invasion11Radiology Radiology 1998; 207:417-221998; 207:417-2222OtoOto HNSHNS 2001;124:150-54 2001;124:150-5433Zinreich et al. Radiology 1988; 169:439-44.
Clinical Presentation: Clinical Presentation: MucinMucin
Mucin is the hallmark of the diseaseMucin is the hallmark of the disease
Allergic MucinAllergic Mucin Gross findings - Gross findings -
indistinguishable indistinguishable from ABPAfrom ABPA Thick viscosityThick viscosity Tan, black, greenTan, black, green
HistologyHistology Non-invasive fungusNon-invasive fungus
GrocottGrocott GiemsaGiemsa PASPAS
EosiniphilsEosiniphils Charcot-Leyden CrxCharcot-Leyden Crx
Diagnostic CriteriaDiagnostic Criteria
CodyCody AllphinAllphin Lowry, SchaeferLowry, Schaefer deShazo, SwaindeShazo, Swain
Bent and KuhnBent and Kuhn PolyposisPolyposis CT findingsCT findings Eosinophilic mucus; Eosinophilic mucus;
no fungal invasionno fungal invasion Gell & Coombs type I Gell & Coombs type I
hypersensitivity hypersensitivity JACI, Oto-HNS 2004JACI, Oto-HNS 2004
Eosinophilic mucinEosinophilic mucin Histo – non invasive Histo – non invasive
fungusfungus Fungal specific IgEFungal specific IgE
Bent, Kuhn, Oto-HNS 1994;111:580-88Meltzer, Hamilos, Hadley, Lanza, Marple, et. al. JACI 2004;114:S155-S212.Bent, Kuhn, Oto-HNS 1994;111:580-88Meltzer, Hamilos, Hadley, Lanza, Marple, et. al. JACI 2004;114:S155-S212.
Eosinophilic Fungal Rhinosinusitis
Eosinophilic Fungal Rhinosinusitis
Mayo Experience – Mayo Experience – Evolution of a PathogenesisEvolution of a Pathogenesis
Ponikau – Improved ability Ponikau – Improved ability to identify nasal fungusto identify nasal fungus 94/101 clinical diagnosis of 94/101 clinical diagnosis of
AFSAFS 100% controls with 100% controls with
fungusfungus Allergy – no difference Allergy – no difference
from general CRS from general CRS populationpopulation
Proposed term “EFRS”Proposed term “EFRS” Shin, Kita – PBMC + Shin, Kita – PBMC +
AlternariaAlternaria IL-5, IL-13, IF-IL-5, IL-13, IF-
Taylor – Fluorescein-Taylor – Fluorescein-labeled chitin stainlabeled chitin stain
Wei – Chemotaxis of Wei – Chemotaxis of eosinophils in presence of eosinophils in presence of tissue/mucin of CRStissue/mucin of CRS Demonstrates Demonstrates
chemoattractant effectschemoattractant effects Ponikau – Ampho B Ponikau – Ampho B
irrigationirrigation 38/51 symptoms improved38/51 symptoms improved
45 with prior surgery45 with prior surgery 35% endoscopically 35% endoscopically
clearedcleared No control group No control group
Ponikau. Mayo Clin Pro. 1999;74:877-84.Shin. JACI (abstract). Shin SH, Kita H et al . AAAAI NY, March 6, 2002Taylor. Oto-HNS 2002;127:377-383.Wei. Laryngoscope 2003;113:303-306.Ponikau. JACI 2002;110:862-866
Ponikau. Mayo Clin Pro. 1999;74:877-84.Shin. JACI (abstract). Shin SH, Kita H et al . AAAAI NY, March 6, 2002Taylor. Oto-HNS 2002;127:377-383.Wei. Laryngoscope 2003;113:303-306.Ponikau. JACI 2002;110:862-866
Why the Difference?Why the Difference?What are we calling What are we calling
“mucin”?“mucin”?
Chitin
GMS
GMS
EFRS AFRS
GMS
Courtesy of Ponikau
Impact of Clinical Findings Impact of Clinical Findings upon Immunologic Dataupon Immunologic Data
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Total IgE Skin test History
Total
Mayo '99
8787
6767
179179
2020
179179
Marple, presented Maryland CRS meeting 2003
AFRS vs EFRS: Why the AFRS vs EFRS: Why the Difference?Difference?
AFRSAFRS EFRSEFRS
Patient selection Patient selection NarrowNarrow Broad Broad Definition of allergic mucinDefinition of allergic mucin GrossGross MicroscopicMicroscopicIncidence of atopyIncidence of atopy Near 100%Near 100% Same as CRSSame as CRSSpecificity vs sensitivitySpecificity vs sensitivity Too specificToo specific Too sensitiveToo sensitive
Marple, ARS Newsletter 2002;21Marple, ARS Newsletter 2002;21
Fungal Specific Humoral Fungal Specific Humoral ResponseResponse
BackgroundBackground Literature to 2004: Literature to 2004:
Fungal allergy plays central role in Fungal allergy plays central role in pathogenesis of AFRSpathogenesis of AFRS
Fungal specific IgE is a critical marker for Fungal specific IgE is a critical marker for AFRSAFRS
Inconsistent definitions for AFRSInconsistent definitions for AFRS Pant/WormaldPant/Wormald
Sub-classified CRS in an attempt to better Sub-classified CRS in an attempt to better understand the role of humoral responses in understand the role of humoral responses in the pathogenesis of the disease the pathogenesis of the disease
Pant H, Laryngoscope 2005;115:601-606.Pant H, Laryngoscope 2005;115:601-606.
Fungal Specific Humoral Fungal Specific Humoral ResponseResponse
DesignDesign 86 study subjects were enrolled86 study subjects were enrolled
Sub-classified based upon following criteriaSub-classified based upon following criteria Presence of macroscopic eosinophilic mucinPresence of macroscopic eosinophilic mucin Presence of fungal allergyPresence of fungal allergy Histologic presence of fungi in eosinophiloc Histologic presence of fungi in eosinophiloc
mucinmucin Cultures obtained from mucinCultures obtained from mucin Serologic testsSerologic tests
Fungal specific IgEFungal specific IgE Fungal specific IgG, IgM, IgAFungal specific IgG, IgM, IgA
Pant H, Laryngoscope 2005;115:601-606.Pant H, Laryngoscope 2005;115:601-606.
Fungal Specific Humoral Fungal Specific Humoral ResponseResponse
spIgE (spIgE (Alternaria Alternaria alternata alternata and and Aspergillus Aspergillus fumagatusfumagatus) failed to ) failed to differentiatedifferentiate EMCRS from controlsEMCRS from controls Subsets within Subsets within
EMCRSEMCRS Culture results only Culture results only
partially matched partially matched those spIgEthose spIgE
Pant H, Laryngoscope 2005;115:601-606Pant H, Laryngoscope 2005;115:601-606
Fungal Specific Humoral Fungal Specific Humoral ResponseResponse
ResultsResults Alternaria alternataAlternaria alternata
and and Aspergillus Aspergillus fumigatusfumigatus IgG3 IgG3 marked the presence marked the presence of EM (p=0.002, 0.004)of EM (p=0.002, 0.004)
spIgG3 spIgG3 Distinguished EMCRS Distinguished EMCRS
from all other controlsfrom all other controls May signify pathogenic May signify pathogenic
significance of IgG3significance of IgG3
Pant H, Laryngoscope 2005;115:601-606Pant H, Laryngoscope 2005;115:601-606
Alternaria spIgG3
Types of Fungal SinusitisTypes of Fungal Sinusitis
InvasiveInvasive FulminantFulminant IndolentIndolent
GranulomatousGranulomatous Non-Non-
granulomatousgranulomatous
Non-invasiveNon-invasive Fungal Ball Fungal Ball
(Mycetoma)(Mycetoma) Saprophytic growthSaprophytic growth Eosinophilic Fungal Eosinophilic Fungal
InflammationInflammation IgE – dependent IgE – dependent
fungal inflammationfungal inflammation Classic AFRSClassic AFRS
Non IgE-dependent Non IgE-dependent fungal rhinosinusitisfungal rhinosinusitis
Eosinophilic Eosinophilic Fungal Fungal Rhinosinusitis Rhinosinusitis (EFRS)(EFRS)
Meltzer, Hamilos, Hadley, Lanza, Marple, et. al. Rhinosinusitis: Establishing Definitions for Clinical Research and Patient Care JACI 2004;114:155-212.
Meltzer, Hamilos, Hadley, Lanza, Marple, et. al. Rhinosinusitis: Establishing Definitions for Clinical Research and Patient Care JACI 2004;114:155-212.
2006: Role of Fungus and 2006: Role of Fungus and Allergy in AFRSAllergy in AFRS
AFRS is a distinct clinical entity that exists AFRS is a distinct clinical entity that exists as a subset of CRS and is strongly associated as a subset of CRS and is strongly associated withwith FungusFungus AllergyAllergy
The central role of allergy in the The central role of allergy in the pathogenesis of AFS is now in questionpathogenesis of AFS is now in question But IgE-mediated sensitivity remains important But IgE-mediated sensitivity remains important
identifieridentifier It is reasonable to direct therapy based upon It is reasonable to direct therapy based upon
the presence of allergy and fungusthe presence of allergy and fungus Evidence-based data is limitedEvidence-based data is limited
AFRS: TreatmentAFRS: TreatmentFungusFungus
ProliferationProliferationAntigen ExposureAntigen Exposure
Immune ResponseImmune ResponseIgE/non-IgEIgE/non-IgE
Mast Cell DegranulationMast Cell DegranulationMucosal EdemaMucosal Edema
InflammationInflammation
Decreased DrainageDecreased DrainageDecreased VentilationDecreased Ventilation
Stasis (Mucin)Stasis (Mucin)
SurgerySurgery Complete removal of Complete removal of
fungal antigenfungal antigen Tissue sparingTissue sparing
ImmunomodulationImmunomodulation Perioperative steroidsPerioperative steroids ImmunotherapyImmunotherapy
Close follow-upClose follow-up Saline irrigationSaline irrigation Office visitsOffice visits
AFSAFS
SurgerySurgery IrrigationIrrigation
ImmunotherapyImmunotherapySteroidsSteroids
AntifungalsAntifungals
Marple,Mabry, AJR 1998:12;263-268Marple,Mabry, AJR 1998:12;263-268
Treatment PrinciplesTreatment Principles
I. Elimination of Fungal Antigen (Surgery)
II. Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic
I. Elimination of Fungal Antigen (Surgery)
II. Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic
Marple, Laryngoscope 2001;111:1006-19.Marple, Laryngoscope 2001;111:1006-19.
Goals of SurgeryGoals of Surgery
Complete Complete extirpation of extirpation of mucin mucin Fungi stimulate Fungi stimulate
inflammationinflammation
Permanent Permanent drainage & drainage & ventilationventilation Preserve mucosaPreserve mucosa ““Complete, but Complete, but
conservative”conservative”
Post-operative Post-operative accessaccess SurveillanceSurveillance
IrrigationIrrigation
Marple,Mabry, AJR 1998:12;263-268Marple,Mabry, AJR 1998:12;263-268
Postoperative RecidivismPostoperative Recidivism
Bent - Near 100% recurrence in absence of medical Bent - Near 100% recurrence in absence of medical treatmenttreatment
Kupferberg - 19/24 patients recurred after d/c of Kupferberg - 19/24 patients recurred after d/c of steroidssteroids
Schubert - 67ptsSchubert - 67pts
Steroids for >2 mo. - 35% recurrence @ 1yrSteroids for >2 mo. - 35% recurrence @ 1yr
Steroids for <2 mo. - 55% recurrence @ 1yrSteroids for <2 mo. - 55% recurrence @ 1yr
Marple, Mabry - 42pts Marple, Mabry - 42pts
Immunotherapy - 10% recurrence @ 12 - 37 mo.Immunotherapy - 10% recurrence @ 12 - 37 mo.Allergy Asthma Proc 1996;17:259-68, Allergy Asthma Proc 1996;17:259-68, Oto-HNS 1997;117:35-41, Oto-HNS 1997;117:35-41, J Allergy Clin Immunol1998;102:395-402, J Allergy Clin Immunol1998;102:395-402, Am J Rhinology 2000;14:223-26Am J Rhinology 2000;14:223-26
Treatment PrinciplesTreatment Principles
I. Elimination of Fungal Antigen (Surgery)
II. Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic
I. Elimination of Fungal Antigen (Surgery)
II. Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic
Immunotherapy for AFS: Immunotherapy for AFS: TheoryTheory
Originally contraindicatedOriginally contraindicated Analogies to ABPAAnalogies to ABPA Theoretically contraindicated in treatment of Theoretically contraindicated in treatment of
ABPA “because of the uncertainties involved”ABPA “because of the uncertainties involved”11
Specific IgG production may elicit immune complex Specific IgG production may elicit immune complex reaction (G&C III)reaction (G&C III)
FergusonFerguson22 - concluded no effect - concluded no effect 7 AFS patients7 AFS patients
2 responded (surgery)2 responded (surgery) 5 no response5 no response
11Middleton & Reed, pp.1395-1414, 1993.Middleton & Reed, pp.1395-1414, 1993.22Ferguson, Abstract AAOA, 1993.Ferguson, Abstract AAOA, 1993.
Could IT be used as a Could IT be used as a part of a comprehensive part of a comprehensive
plan?plan? SurgerySurgery
Remove antigenic Remove antigenic load!load!
Allergic evaluationAllergic evaluation RAST (or skin test)RAST (or skin test)
3 most relevant fungal 3 most relevant fungal antigensantigens
Non-fungal antigensNon-fungal antigens
Skin test (or RAST) Skin test (or RAST) for additional fungifor additional fungi
Allergy treatmentAllergy treatment Treat for all Treat for all
positive reactorspositive reactors Do notDo not treat only treat only
cultured funguscultured fungus Treat non-fungal Treat non-fungal
reactive antigensreactive antigens
Mabry, Marple, Mabry Oto-HNS 1999;121:252-4Mabry, Marple, Mabry Oto-HNS 1999;121:252-4
Treatment of AFS: a comparison Treatment of AFS: a comparison trial of postoperative IT with trial of postoperative IT with
specific fungal antigensspecific fungal antigens11
Cross-sectional Cross-sectional study of 22 AFS study of 22 AFS ptspts 2 groups matched 2 groups matched
for preop severity for preop severity of disease (CT&PE)of disease (CT&PE)
Similar surgerySimilar surgery 11 tx’d with IT11 tx’d with IT 11 no IT11 no IT
11Folker, Marple, Mabry, Mabry, Laryngoscope 108:1623-27, 1998Folker, Marple, Mabry, Mabry, Laryngoscope 108:1623-27, 1998
EvaluationEvaluation Regular exam and Regular exam and
endoscopic staging endoscopic staging (Kupferberg)(Kupferberg)
Chronic Sinusitis Chronic Sinusitis Survey (Glichlick & Survey (Glichlick & Metson)Metson)
Treatment of AFS: a comparison Treatment of AFS: a comparison trial of postoperative IT with trial of postoperative IT with
specific fungal antigensspecific fungal antigens11
Follow-upFollow-up Overall mean f/u Overall mean f/u
33 mos.33 mos. IT group IT group
Mean - 30 mos.Mean - 30 mos. Range - 12-43 mos.Range - 12-43 mos.
Non-IT groupNon-IT group Mean - 35 mos.Mean - 35 mos. Range - 12-50 mos.Range - 12-50 mos.
11Folker, Marple, Mabry, Mabry, Laryngoscope 108:1623-27, 1998Folker, Marple, Mabry, Mabry, Laryngoscope 108:1623-27, 1998
CorticosteroidsCorticosteroids IT groupIT group
Systemic - 0%Systemic - 0%
Non-IT groupNon-IT group Systemic - averaged Systemic - averaged
2 courses per year2 courses per year
Endoscopic Mucosal Endoscopic Mucosal StagingStaging
Folker, Marple, Mabry, Mabry, Laryngoscope 108:1623-27, 1998Folker, Marple, Mabry, Mabry, Laryngoscope 108:1623-27, 1998
0
2
4
6
8
10
Stage 0 Stage 1 Stage II Stage III
ITControl
P<0.02
Chronic Sinusitis SurveyChronic Sinusitis Survey
Folker, Marple, Mabry, Mabry, Laryngoscope 108:1623-27, 1998Folker, Marple, Mabry, Mabry, Laryngoscope 108:1623-27, 1998
71
49
0
10
20
30
40
50
60
70
80
CSS Score
IT Control
p<0.05
Treatment PrinciplesTreatment Principles
I. Elimination of Fungal AntigenElimination of Fungal Antigen (Surgery)(Surgery)
II. Control of RecurrenceII. Control of Recurrence
ImmunomodulationImmunomodulation Antifungal R Antifungal Rxx
IT IT SteroidsSteroids Topical Systemic Topical Systemic
I. Elimination of Fungal AntigenElimination of Fungal Antigen (Surgery)(Surgery)
II. Control of RecurrenceII. Control of Recurrence
ImmunomodulationImmunomodulation Antifungal R Antifungal Rxx
IT IT SteroidsSteroids Topical Systemic Topical Systemic
Corticosteroids: Corticosteroids: RationaleRationale
Concept Concept originates from originates from the treatment of the treatment of ABPAABPA Anti-inflammatoryAnti-inflammatory ImmunomodulationImmunomodulation
Systemic Systemic Used in some form Used in some form
for all patients with for all patients with AFSAFS
Topical Topical Standard therapyStandard therapy No published No published
evidence of effect evidence of effect in AFSin AFS
Effect demonstrated Effect demonstrated in NPin NP
CorticosteroidsCorticosteroids
BentBent11 Universal Universal
recurrence of AFS recurrence of AFS in following in following discontinuation of discontinuation of corticosteroidscorticosteroids
SchubertSchubert22 - 67 pts - 67 pts Corticosteroids < 2moCorticosteroids < 2mo
55% recurrence at 1yr55% recurrence at 1yr Shorter time to Shorter time to
recurrencerecurrence Higher total IgEHigher total IgE
Corticosteroids > 2moCorticosteroids > 2mo 35% recurrence at 1yr35% recurrence at 1yr Longer time to Longer time to
recurrencerecurrence Lower total IgELower total IgE
11Bent, Kuhn, Allergy Asthma Proc 17:259-68, 1996Bent, Kuhn, Allergy Asthma Proc 17:259-68, 199622Schubert, Goetz, J Allergy Clin Immun 103:395-402, 1998Schubert, Goetz, J Allergy Clin Immun 103:395-402, 1998
Treatment PrinciplesTreatment Principles
I. Elimination of Fungal Antigen (Surgery)
II. Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic
I. Elimination of Fungal Antigen (Surgery)
II. Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic
Systemic Antifungals Systemic Antifungals DenningDenning
Use of itraconazole for ABPAUse of itraconazole for ABPA Decrease in total IgEDecrease in total IgE Decrease in systemic corticosteroid useDecrease in systemic corticosteroid use
FergusonFerguson Limited available dataLimited available data Potential drug related morbidityPotential drug related morbidity Cost of treatmentCost of treatment
Rains Rains Safety of itraconazoleSafety of itraconazole
KennedyKennedy Terbenifine offered no benefit to the treatment Terbenifine offered no benefit to the treatment
of CRSof CRS11Denning, et al, Chest 100:813-19, 1991Denning, et al, Chest 100:813-19, 199122Ferguson, Arch Otolaryngol Head Neck Surg 124:1174-77, 1998Ferguson, Arch Otolaryngol Head Neck Surg 124:1174-77, 1998
May limitMay limitusefulness ofusefulness of
therapytherapy
Systemic AntifungalsSystemic Antifungals Alternate effect of antifungalsAlternate effect of antifungals
Kanda et.alKanda et.al CDCD33/CD/CD2828 cells from atopic derm and cells from atopic derm and
controlscontrols In vitro T-cell helper-1 (TIn vitro T-cell helper-1 (THH1) and T-cell 1) and T-cell
helper-2 (Thelper-2 (THH2) cytokines studied in 2) cytokines studied in response to antimycoticsresponse to antimycotics
ResultsResults Azole derivatives suppressed expression of Azole derivatives suppressed expression of
IL-4 and IL-5 by reducing 3,5 cAMP signal IL-4 and IL-5 by reducing 3,5 cAMP signal
Kanda N. Journal of Investigative Dermatology. 117(6):1635-46, 2001 Dec.
Topical AntifungalsTopical Antifungals Test of fungal hypothesisTest of fungal hypothesis
MethodsMethods Double blind placebo Double blind placebo
controlledcontrolled 24 CRS subjects randomized24 CRS subjects randomized
Ampho B irrigation - 10Ampho B irrigation - 10 Saline control - 14Saline control - 14
ResultsResults CT scoresCT scores SNOT – 20 – no sig changeSNOT – 20 – no sig change Endoscopy (7/10, 5/14)Endoscopy (7/10, 5/14) IL-5 – no sig changeIL-5 – no sig change Eosinophils – no sig changeEosinophils – no sig change Alternaria – no changeAlternaria – no change
Conclusion – Ampho B Conclusion – Ampho B worksworks
Ponikau, et al. JACI 2005;115:125-31.
StratificationStratificationIssuesIssues
AlternariaAlternaria No change over 6 No change over 6
monthsmonths Does this support Does this support
hypothesis?hypothesis? Stratification IssuesStratification Issues
DemographicsDemographics Inflammatory Inflammatory
MediatorsMediators EDNEDN IL-5IL-5
Ponikau, et al. JACI 2005;115:125-31
Topical AntifungalsTopical Antifungals Test of fungal Test of fungal
hypothesishypothesis MethodsMethods
Double blind placebo Double blind placebo controlledcontrolled
74 CRS subjects 74 CRS subjects randomizedrandomized
Ampho B sprayAmpho B spray Saline controlSaline control
ResultsResults 60 completed the study60 completed the study
Conclusion – no effectConclusion – no effect
Controversy in delivery Controversy in delivery
Weshta, et al. JACI 2004;113:1122-28.
Recidivism after Recidivism after treatmenttreatment
Bent - Near 100% recurrence in absence of medical Bent - Near 100% recurrence in absence of medical treatmenttreatment
Kupferberg - 19/24 patients recurred after d/c of Kupferberg - 19/24 patients recurred after d/c of steroidssteroids
Schubert - 67ptsSchubert - 67ptsSteroids for >2 mo. - 35% recurrence @ 1yrSteroids for >2 mo. - 35% recurrence @ 1yrSteroids for <2 mo. - 55% recurrence @ 1yrSteroids for <2 mo. - 55% recurrence @ 1yr
Marple, Mabry - 42pts Marple, Mabry - 42pts Immunotherapy - 10% recurrence @ 12 - 37 mo.Immunotherapy - 10% recurrence @ 12 - 37 mo.
Marple, Newcomer - 17pts followed 4 - 11yrs.Marple, Newcomer - 17pts followed 4 - 11yrs.1/17 with recurrence of AFS1/17 with recurrence of AFSNo decrease in fungal IgENo decrease in fungal IgENo difference in treatment armsNo difference in treatment arms
Allergy Asthma Proc 1996;17:259-68, Allergy Asthma Proc 1996;17:259-68, Oto-HNS 1997;117:35-41, Oto-HNS 1997;117:35-41, J Allergy Clin Immunol1998;102:395-402, J Allergy Clin Immunol1998;102:395-402, Am J Rhinology 2000;14:223-26Am J Rhinology 2000;14:223-26Oto-HNS: 2002 Oto-HNS: 2002 127(5) 361-6127(5) 361-6
Elimination of Fungal Antigen
Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic
Elimination of Fungal Antigen
Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic
ConclusionConclusion
AFS remains AFS remains intriguingintriguing Subset of CRSSubset of CRS SurgerySurgery
Crucial part of Crucial part of treatmenttreatment
Medical follow-up Medical follow-up appears crucial to appears crucial to long-term successlong-term success
Need for evidence-Need for evidence-based studiesbased studies