Since August 1994, we have treated patients with histologically proven allergic fungal sinusitis with surgery followed by immunotherapy, employing fungal and nonfungal antigens to which hypersensitivity has been demonstrated. Our results continue to be encouraging. Not only have we encountered no indication that fungal immunotherapy has worsened these patients' condition or caused a recurrence of disease, we have confirmed dramatic improvement in these patients compared with the generally accepted course of this disease. Of 11 patients who have received immunotherapy for 1 to 3 years (mean 28 months), none has required regular or frequent treatment with a single brief course of systemic steroids, and only three are receiving topical nasal steroids. No repeat surgeries for recurrent allergic fungal sinusitis have been required in the treatment group. This combination of surgery and immunotherapy has continued to prove beneficial, and we urge others to consider this approach to therapy.
Results from this study indicate that specific IT with fungal antigens improves patient outcome in AFS.
Although the treatment of allergic fungal sinusitis with specific immunotherapy after surgical intervention has proved successful, the question of what happens when such injections are discontinued remains unanswered. In this initial, admittedly small series, no recurrence has been noted in follow-up of 7 to 17 months.
Recommendations to withhold immunotherapy with fungal antigens from patients with allergic fungal sinusitis (AFS) have been based primarily on retrospectively reviewed, anecdotal case reports and theoretical considerations. A study that was approved by the investigational review board of our institution is ongoing in our department to administer immunotherapy with relevant fungal antigens to patients with histologically proven AFS. After 1 year, no instances of worsening of symptoms as a result of this therapy have been observed. Objective measurement of improvement has been difficult, but our initial clinical impression is that this treatment regimen has resulted in significant reduction in the reaccumulation of crusts and allergic mucin within the sinuses, has led to a reduction in the use of topical nasal steroids, and has made systemic steroid therapy unnecessary, thereby improving the quality of life of the patient. A further study of immunotherapy for patients with AFS is recommended, and suggestions for modification of the current protocol are presented.
Since August 1994 we have followed a protocol of treating patients with histologicaily proven allergic fungal sinusitis with surgical extirpation of the involved sinuses, followed by immunotherapy using both fungal and nonfungal antigens to which hypersensitivity is demonstrated by in vitro and skin testing methods. Despite predictions to the contrary, we have encountered no evidence that these injections have worsened the condition of any patients. Rather, we have noted a marked decrease in nasal crusting in all patients, with a minimum amount of recurrent polypoid mucosa and a lessened or absent requirement for corticosteroids (systemic or topical). Two patients treated with immunotherapy required systemic corticosteroids and subsequent revision surgery for residual disease that was present before the start of immunotherapy, and they have done well since. Our experience indicates that the triad of adequate surgery, frequent follow-up and medical management , and immunotherapy with relevant fungal and nonfungal antigens represents an effective means of treating patients with allergic fungal sinusitis. Nevertheless, an even longer period of study will be necessary to provide the final answer regarding the rome of immunotherapy in the treatment of allergic fungal sinusitis. (Otoloryngol Head Neck Surg 199'7;117:367-71.) In August 1994 we began treating patienls with proven allergic fungal sinusitis (AFS) with a regimen that included surgery followed by immunotherapy for relevant fungal antigens. Despite theoretical objections to administering fungal material to patients with AFS, initial results were encouraging. We previously reported that nine patients who had received fungal immunother-apy for 4 to 12 months (average, 7.4 months) showed no adverse effects from the injections. 1 Within 8 weeks of the start of immunotherapy, cessation of crust and debris formation was observed, with no patients requiring sys-temic corticosteroids and seven of the nine patients able to discontinue topical steroids. Although we believed that it was important that we had shown no adverse effects from this immunotherapy, it was our feeling that only a longer term study would provide a c2earer answer From the 14 patients with AFS began immunotherapy with fungal antigens. In each case the diagnosis of AFS had been established by characteristic clinical findings, surgical findings that included the presence of typical allergic mucin, and histopathologic demonstration of eosinophilic debris with confirmation of noninvasive fungal elements by special stains and/or positive fungal cultures. 2 Patients were entered into the study at least 1 month after surgical extirpation of the involved sinuses. These patients were not classified by a preoperative staging system. However, all demonstrated pansinusitis with multiple polyps, representing a severe involvement with AFS. Eleven fungal antigens were tested by dilutional intradermal testing (Table 1). In addition, RAST levels of allergen-specific IgE were determined for 12 non-fungal antigens, ...
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