Allergic fungal sinusitis in children

doi:10.1016/S1081-1206(10)61237-9

Annals of Allergy, Asthma & Immunology

Volume 96, Issue 2, February 2006, Pages 286-290

https://doi.org/10.1016/S1081-1206(10)61237-9 Get rights and content

Background

Allergic fungal sinusitis (AFS) has been characterized in adults presenting with chronic sinusitis. Rare reports allude to a similar disease in children.

Objective

To characterize the features of AFS in children.

Methods

Children referred to otolaryngology clinics at Arkansas and LeBonheur Children's Hospitals for chronic sinusitis during a 12-year period were studied. This retrospective analysis reviews the following: clinical presentation, laboratory evaluations, radiographic and pathologic findings, and surgical intervention. Twenty patients (age range, 7-18 years; mean age, 12.5 years; median age, 16 years) met previously published criteria for AFS. Thirteen patients were male and 7 were female. Thirteen were African American and 7 were white.

Results

Presentation at diagnosis included the following: atopy (n = 20), nasal symptoms (n = 20), recurrent sinusitis (n = 18), nasal polyps (n = 18), recurrent headaches (n = 12), asthma (n = 11), proptosis (n = 10), and ocular symptoms (n = 10). All had radiographic evidence of sinusitis and allergy to fungal organisms. IgE levels were elevated in 8 of 9 patients, and 10 of 15 patients had eosinophilia. Surgical specimens demonstrated allergic mucin (n = 11), Charcot-Leyden crystals (n = 2), hyphae or fungal debris (n = 9), and fungal growth (n = 17). All patients underwent endoscopic sinus surgery, with 11 requiring multiple surgical procedures. Postoperatively, 19 patients received intranasal and oral steroids, and all had nasal saline washes. Eleven patients (9 who had undergone multiple surgical procedures) were treated with immunotherapy. Relapse was seen in 55% of patients at 1 year of follow-up.

Conclusion

AFS presents with a higher incidence of proptosis in children when compared with adults. Typically, AFS occurs in atopic children with refractory sinus disease, requiring a high index of suspicion for evaluation and aggressive treatment.

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It is possible this is related to increased exposure to antibiotic therapy with increasing age or other changes in microbiome composition over time. The literature has previously reported a higher proportion of AFS in AA children compared to other races [8,19]. Excluding these patients with a severe and unique phenotype of disease, there was not a significantly higher rate of fungal cultures in this population.
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Retrospective study of patients undergoing sinus surgery at a tertiary care pediatric hospital to determine the period prevalence of positive fungal cultures in subgroups of patients.
400 children from 2012 to 2019 were included. 265 patients had surgical culture results available. Of the 52 patients with CF 11 (21%) had positive fungal sinus cultures. Similarly, 28% of the 25 patients with non-CF nasal polyps had positive cultures. Only 8.2% of 110 CRS without polyps patients had positive cultures, significantly fewer than other subgroups (X² (1, N = 240) = 17.22, p < 0.01).
Children with CF and children with nasal polyps had more frequent positive fungal cultures than children without nasal polyps having sinus surgery. This confirms that pediatric CF and pediatric CRS with polyps represent unique populations to study the impact of fungal infection in CRS. Further research is required to determine if these fungi represent colonization or contribute to the inflammatory environment of the airways.
Pediatric allergic fungal rhinosinusitis with extensive intracranial extension – Case report and literature review
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Over the last two decades, allergic fungal sinusitis (AFRS) has become increasingly common. It’s defined as a noninvasive, benign inflammatory fungal disease of the sinuses which develops in young adults and adolescents. Patients often complain of symptoms like nasal obstruction, congestion, purulent or clear rhinorrhea, anosmia, and headache. The cases are also presenting clinically with symptoms like epiphora and eye discharge as a result of nasolacrimal gland obstruction. In this article, we will review a unique case of AFRS, in an adolescent male. The case was diagnosed with intracranial extradural extension.
A 15 years old male with AFRS was diagnosed and managed. The case was diagnosed to have allergic fungal sinusitis based on Bent and Khun diagnostic criteria, presented with intracranial extradural extension.
In our case, there were no irreversible complications except a recurrent polyp. The case was mainly complaining of long-standing nasal discharge and on-off headache with no orbital complaint and no other neurological signs. This shows a presentation of the fungal sinusitis and the need for aggressive intervention for AFRS both medically and surgically for pediatric patients as well.
To conclude, despite AFRS being categorized as a benign, non-invasive disease, its presentation can range from simple nasal obstruction to signs and symptoms of intraorbital and/or intracranial complications; with pediatric cases being very aggressive. Careful clinical evaluation, detailed histopathological examination, navigation assisted endoscopic sinus surgery followed by steroid treatment, and a lifelong follow up to manage the recurrence.
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The allergic airway diseases, including chronic rhinosinusitis (CRS), asthma, allergic bronchopulmonary mycosis (ABPM) and many others, comprise a heterogeneous collection of inflammatory disorders affecting the upper and lower airways and lung parenchyma that represent the most common chronic diseases of humanity. In addition to their shared tissue tropism, the allergic airway diseases are characterized by a distinct pattern of inflammation involving the accumulation of eosinophils, type 2 macrophages, innate lymphoid cells type 2 (ILC2), IgE-secreting B cells, and T helper type 2 (Th2) cells in airway tissues, and the prominent production of type 2 cytokines including interleukin (IL-) 33, IL-4, IL-5, IL-13, and many others. These factors and related inflammatory molecules induce characteristic remodeling and other changes of the airways that include goblet cell metaplasia, enhanced mucus secretion, smooth muscle hypertrophy, tissue swelling and polyp formation that account for the major clinical manifestations of nasal obstruction, headache, hyposmia, cough, shortness of breath, chest pain, wheezing, and, in the most severe cases of lower airway disease, death due to respiratory failure or disseminated, systemic disease.
The syndromic nature of the allergic airway diseases that now include many physiological variants or endotypes suggests that distinct endogenous or environmental factors underlie their expression. However, findings from different perspectives now collectively link these disorders to a single infectious source, the fungi, and a molecular pathogenesis that involves the local production of airway proteinases by these organisms. In this review, we discuss the evidence linking fungi and their proteinases to the surprisingly wide variety of chronic airway and systemic disorders and the immune pathogenesis of these conditions as they relate to environmental fungi. We further discuss the important implications these new findings have for the diagnosis and future therapy of these common conditions.
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In the post-operative period, saline nasal irrigation, nasal corticosteroid sprays, and oral steroids are administrated to avoid recurrence [7]. Antifungal nasal agents such as fluconazole seem to be useful in preventing progression of disease and/or improving symptoms, but to date limited data is available [7]. In addition to medical treatments, endoscopic cleanings should be periodically scheduled after surgery, and patients should be followed for a very long period [10].
to report the alternating nature of allergic fungal rhinosinusitis in children in the Eastern part of Saudi Arabia and to review the experience of King Fahad Specialist Hospital in the diagnosis and management of alternating allergic fungal rhinosinusitis in children.
An 8 years old Saudi girl with alternating allergic fungal rhinosinusitis was diagnosed and managed. The patient was diagnosed to have unilateral left allergic fungal rhinosinusitis and underwent endoscopic sinus surgery and cleaning of the left sinuses from polyps, mud and mucin. One year postoperatively the patient developed AFRS in the contralateral right side.
involvement of the contralateral sinuses in children with AFRS is uncommon. The normal uninvolved sinus should be involved in the routine endoscopic examination and the post-operative treatment in order to minimize the risk of disease recurrence.
The Influence of Upper Airway Disease on the Lower Airway
2019, Kendig's Disorders of the Respiratory Tract in Children
Upper airway disease, including chronic rhinitis and rhinosinusitis, affect most children with asthma. Over the past two decades, our understanding of the connection between the nose, paranasal sinuses, and lungs has evolved significantly. A growing body of population-based studies has established that allergic rhinitis in children acts as a critical independent risk factor for the development of asthma and that specific allergen immunotherapy has been shown to reduce the risk for developing asthma by approximately 50%. A number of physiologic mechanisms underlie the apparent connection between the upper and lower airways, particularly the systemic spread of inflammation from the nose and sinuses to the lungs. A large number of studies have examined the effect of nasal and sinus therapy, including both medical and surgical treatments, on subjective and objective parameters of asthma. While there is a paucity of randomized, blinded studies, the existing data do suggest that treatment of rhinitis and sinusitis have a beneficial effect on asthma symptoms, pulmonary function, and bronchial hyperresponsiveness.
ACR Appropriateness Criteria <sup>®</sup> Sinusitis-Child
2018, Journal of the American College of Radiology
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ORIGINAL ARTICLESAllergic fungal sinusitis in children

Background

Objective

Methods

Results

Conclusion

J Allergy Clin Immunol.

J Allergy Clin Immunol.

Otolaryngol Head Neck Surg.

J Allergy Clin Immunol.

Otolaryngol Head Neck Surg.

Otolaryngol Head Neck Surg.

Medical treatment of allergic fungal sinusitis

Ann Allergy Asthma Immunol.

Pathologic findings in allergic aspergillus sinusitis: a newly recognized form of sinusitis

Am J Surg Pathol.

Fungal sinusitis: an update

Ann Allergy Asthma Immunol.

ORIGINAL ARTICLES
Allergic fungal sinusitis in children