Contralateral sinus involvement of surgically treated unilateral allergic fungal rhinosinusitis

Abstract

Recurrence of allergic fungal rhinosinusitis (AFRS) is well recognized. However, there is scarcity in the literature describing involvement of the non-diseased sinuses. We aimed to evaluate the recurrence forms of unilateral AFRS as well as to study the possible predictor factors of developing the disease in the contralateral side. Patients with exclusive unilateral AFRS from (2010 to 2015) were enrolled in multi-institutional case-control study. All patients were evaluated after endoscopic sinus surgery for recurrence. Patient's records were reviewed for demographics, medical treatment, and clinical, radiological, and surgical data. A total of 68 patients were identified. Delayed contralateral involvement after the initial surgery was found in 30.8% with mean duration of recurrence 16.9 months. A significant association was found with the presence of pre-operative contralateral symptoms and signs of inflammation (OR 3.49, 95% CI 1.19-10.22, p value 0.02). Post-operative use of budesonide irrigation was associated with less contralateral involvement (OR 0.11, 95% CI 0.01-0.87, p value 0.01). Association of other variables like: comorbidities, perioperative use of systemic steroid, radiological signs, extent of surgery, additional surgery to the contralateral side, and post-operative use of systemic steroids did not show statistical significance. Involvement of the contralateral sinuses in 30% of unilateral AFRS cases is considered significant. The non-diseased sinuses should be involved in the routine endoscopic examination and post-operative treatment. Further studies are necessary to investigate the possibility of prophylactic surgical intervention of the non-diseased sinuses.

What is appropriate management for the contralateral uninvolved side in unilateral allergic fungal rhinosinusitis?

“…Previous studies have demonstrated decreased recurrence rates of AFRS in patients treated with postoperative topical steroids, though not directly evalauting patterns of recurrence [10–13]. AlQahtani et al [4 ▪▪ ] addressed this issue with a retrospective study while also reinforcing the association between unilateral AFRS and risk of recurrence of the contralateral undiseased side. Sixty-eight patients with initially unilateral AFRS who underwent targeted sinus surgery were evaluated for recurrence.…”

“…Allergic fungal rhinosinusitis (AFRS) is recognized as a benign, noninvasive, fungal sinusitis and is a subtype of chronic rhinosinusitis with nasal polyposis (CRSwNP) [1]. AFRS involves an exuberant inflammatory response to fungus, and is classically diagnosed via the Bent and Kuhn criteria [2,3,4 && ,5]. The Bent and Kuhn criteria, first described in 1994, distinguishes AFRS from other CRSwNP subtypes and must include a type I hypersensitivity, nasal polyposis, characteristic findings on computed tomography (CT), eosinophilic mucin without fungal invasion, and a positive fungal stain [5].…”

Allergic Fungal Rhinosinusitis in Saudi Arabia: A Review of Recent Literature

“…Marglani et al [ 30 ] have reported a 25% contralateral recurrence after a mean duration of two years. Upon studying the risk factors for contralateral recurrence, AlQahtani et al [ 85 ] have reported a significant association between preoperative symptoms and signs of contralateral inflammation (odds ratio (OR): 3.49) and postoperative use of budesonide irrigation (OR: 0.11) (Table 1 ).…”

Pediatric allergic fungal rhinosinusitis: optimizing outcomes

“…To date, due to the lack of available evidence, there is no consensus on the extent of FESS surgery that should be performed in the pediatric AFRS population. Interestingly in a study evaluating patients presenting with unilateral AFRS, 30% progressed to contralateral involvement at a later date with preemptive surgery on the unaffected side not delaying contralateral disease [29,30]. For this reason, and the added complexity of pediatric FESS due to the narrow operating confines, it is our opinion that FESS surgery should be targeted to the involved sinuses to remove the fungal disease and facilitate access for topical treatments.…”

“…The advantage of budesonide irrigations over sprays and nebulizers is the increased delivery of the steroid to the sinuses after surgery. One study investigating its use in AFRS did show that it also may reduce the risk of both recurrence and delayed contralateral involvement in unilateral AFRS [30]. At some institutions, budesonide irrigation is already routinely used for pediatric AFRS once the patient has completed the oral corticosteroid taper [2,43].…”