What is the role of surgery in the treatment of allergic fungal sinusitis (AFS)?

Updated: Mar 16, 2018
  • Author: John E McClay, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

The invariable components of combination therapy still are surgical removal of the inciting fungal allergic mucin and marsupialization of the involved sinuses. For this reason, surgery has played an important role in the management of allergic fungal sinusitis (AFS) since its earliest reports. An aggressive surgical posture initially was adopted because of a perceived risk of fungal invasion. This frequently was accomplished through the use of open antrostomies with radical removal of mucosa, intranasal sphenoethmoidectomies, and Lynch frontoethmoidectomies. Despite such aggressive therapy, recidivism remained high, and most patients required multiple surgical procedures.

Clinical appearance of the disease often confused the underlying diagnosis, further influencing surgeons to adopt a more radical stance. Radiographic evidence of invasion (which really was extension) into adjacent spaces (eg, orbit, intracranial cavity) frequently was interpreted as evidence of malignancy or invasive fungal disease. It logically followed that surgical approaches appropriate for these serious conditions (eg, lateral rhinotomy, facial degloving approaches, craniofacial resection) would be performed.

Increased acceptance of specific immunologic hypersensitivity as the cause of allergic fungal sinusitis (AFS) has led to changes in its management. These changes have involved the medical and surgical arms of therapy. While systemic use of antifungal medications largely has been replaced by immunomodulation, radical surgery for allergic fungal sinusitis (AFS) has given way to more conservative, tissue-sparing approaches. Mabry et al refer to this surgery as conservative but complete, relying almost completely on endoscopic techniques.

A retrospective study by Masterson et al indicated that for patients with allergic fungal rhinosinusitis, quality-of-life improvement following endoscopic sinus surgery is significantly greater than for patients with nonfungal chronic rhinosinusitis without nasal polyposis, at 9- and 12-month follow-up. Quality of life was evaluated via the 22-item Sino-Nasal Outcome Test (SNOT-22). [26]


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