Antifungal treatment and chronic rhinosinusitis

Abstract

Chronic rhinosinusitis (CRS) is an inflammatory disease with a multifactorial etiology. Antifungal therapy is not routinely used to treat it. However, evidence implicating fungi in some forms of CRS recently has been published. Controversy exists as to whether fungi identified in sinonasal cultures are always pathogenic. Immunologic evidence supporting the role of fungi in the pathogenesis of CRS is also debated. Topical antifungal therapy is more widely used than oral therapy, with amphotericin B irrigation being the most common. Although some studies show benefit from this irrigation, others refute the efficacy. Although oral antifungal agents are used uncommonly, itraconazole is the most commonly used drug. The efficacy of oral itraconazole in CRS has never been assessed in a clinical trial. Given the current evidence, the use of antifungals to treat CRS is controversial and has limited indications.

Some chronic rhinosinusitis patients have elevated populations of fungi in their sinuses

“…No antifungal agent tested in vitro was able to suppress the growth of all of these potentially relevant fungi. Amphotericn B, which has been used in many of the clinical trials against CRS, 10,20,23 had no measurable effect on the growth of C herbarum. Fluconozole was generally the least effective of the agents in inhibiting growth.…”

Effectiveness of itraconazole on clinical symptoms and radiologic findings in patients with recurrent chronic rhinosinusitis and nasal polyposis

“…Previous reports with itraconazole did not show any side-effects;[22] but up to 13% in different studies had elevated liver enzyme. [2324] Systemic corticosteroid have a lot of proved benefit in chronic sinusitis and polyposis, but its side-effects limited its usage as a treatment of choice.…”

Oral antifungal therapy for chronic rhinosinusitis and its subtypes: a systematic review

“…Query of the bibliographies cross-referenced an additional 28 abstracts, yielding 60 full-length articles for review. Thirty-two studies were excluded due to no oral antifungal treatment (26) and wrong disease entity (6). A total of 28 articles were included in the evidence-based review.…”

“…5 The introduction of the fungal hypothesis has led to investigation of topical and oral antifungal therapies for CRS and its subtypes. 6 Despite preliminary studies suggesting potential utility of topical amphotericin B irrigations, 7,8 recent double-blind placebo-controlled randomized multicenter trial demonstrated no difference in mean visual analog scores (VAS), quality-of-life scores, nasal endoscopy scores, or polyp scores between topical amphotericin B and placebo groups. 9 Comparatively, the role of oral antifungals for treatment of CRS remains largely unexplored.…”