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Allergic Fungal Rhinosinusitis Treatment: Clearing Out the “Peanut Butter”
Julia Casazza • Nov 28, 2023 • 67 hits
Allergic fungal rhinosinusitis (AFRS) results from an overzealous immune response targeted at fungal spores. This immune response manifests as a thick eosinophilic mucus resembling peanut butter. Allergic fungal rhinosinusitis treatment is important, because if left untreated, AFRS can cause headaches, visible distortion of sinus anatomy, and even vision loss. Fortunately, judicious sinus surgery, followed by regular sinus rinses, quells causative inflammation in most patients. AFRS expert Dr. Amber Luong, a rhinologist at UTHealth Houston, shares her pearls for treating this “sticky situation.”
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• The extent of allergic fungal rhinosinusitis surgery (sinus surgery) needed to treat AFRS is actively debated. Dr. Luong advocates for a full-house Functional endoscopic sinus surgery (FESS) limited to the side with disease. In cases with bilateral sinusitis (which are much less common), she recommends performing a full house FESS bilaterally.
• Steroids curb inflammation responsible for AFRS disease progression. Dr. Luong recommends placing a steroid-eluting stent and starting patients on a short course of prednisone in the peri-operative period.
• After allergic fungal rhinosinusitis surgery, patients should perform twice-daily sinus rinses to continuously wash out any remaining fungal spores. Dr. Luong recommends budesonide and mupirocin in saline.
Table of Contents
(1) Allergic Fungal Rhinosinusitis Surgery Tips
(2) Curbing Peri- and Post-Operative Inflammation with Steroids
(3) Post-Operative Care for Allergic Fungal Rhinosinusitis Patients
Allergic Fungal Rhinosinusitis Surgery Tips
The goal of allergic fungal rhinosinusitis surgery is to remove all visible mucin. In more severe cases, sinus anatomy may be distorted due to chronic mucus buildup. When performing surgery on distorted sinonasal anatomy, Dr. Luong uses an intraoperative navigation system and keeps scopes with different angles on hand. Using a combination of curettes, forceps, and (much less commonly) a microdebrider, Dr. Luong removes mucus from affected sinuses. She then “power-washes” out any residual mucus using a hydrodebrider followed by Afrin-soaked cottonoids.
Controversy exists over the extent of sinus surgery required for allergic fungal rhinosinusitis treatment. Dr. Luong recommends a unilateral “full-house” FESS for patients with unilateral disease. In patients with unilateral disease and deviated septa, she avoids revising the septum to avoid crossover between diseased and healthy sides. She does not send pathology or cultures for clinical use, as most people, including those without any sinusitis, have fungus in their nasal cavities.
[Dr. Ashley Agan]
I want to back up and talk a little bit more about the specifics of allergic fungal rhinosinusitis surgery. You mentioned one big thing is just having the right tools at your disposal to be able to reach and get into all these nooks and crannies where this thick peanut butter mucin is packed in there. Can we unpack that a little bit more?
[Dr. Amber Luong]
Sure. I think the one that's most challenging on a normal basis, yes, there's these patients that have these crazy expanded frontals that expand posteriorly and intracranial cavity area, but not actually in the cavity itself. The most common one that's really frustrating to deal with is the maxillary sinus. Most patients, it is involved. There are different tricks that I've learned over the years that I use. Going in and then just the normal suctioning.
Then, when you start getting into areas where it's really low on the floor and their sinus cavity is significantly lower than even the nasal floor, but oftentimes I don't necessarily have to do, let's say, a mega-antrostomy or, do anything like that because the polyps and the mucin has already expanded the opening of the maxillary sinus so much. But still, sometimes in those areas, lower and anterior, it's really challenging to get all that mucin out. The maxillary forceps has this curve and it has a Blakesley grasping handle at the end. That works really well in using that to mix the mucin around to try to dislodge it.
I also will use various different curettes, like a 90-degree curette sometimes can help me reach into those areas. Those instruments are designed for the frontal, but because of the curvature of the instruments, it allows me to get to some of the anterior, some of the lateral aspects of the area. It is really important for you to take advantage of your different angled scopes so you can see in those areas. I will go into my even the 70-degree scope just to get a good look to make sure I haven't missed anything. I use warm saline on syringes. After I think I've gotten everything out, I'll irrigate with lots of saline and sometimes the warm saline is helpful to help dislodge it.
There are more devices that will allow you to basically power wash all of your sinuses. I'll use that, a hydrodebrider. The poor man's way is to do syringes and irrigate it and those are very effective too. Maybe even after you feel like you've gotten a good clean out, I'll go and use the hydrodebrider. It's an instrument that also allows you to curve the ends in different angles and then you attach like a liter of saline and it allows you to just power wash. It looks like literally a power washer and you just power wash all your sinuses at the end of the case. I'll do that at the end of the case.
Other things at the maxillary sinus, if I feel like there's some areas where the mucin won't come out, I'll wick it out. I'll use like Afrin soaked cottonoids and I'll stuff that maxillary sinus with a ton of cottonoids and then sometimes that will wick out some of the mucin that's trapped in there. Then again, other frontal instruments can be helpful. There's a whole bunch of non-biting giraffes that you can try, again, just to get at those angles, just to get everything out. That can be the most challenging area.
[Dr. Gopi Shah]
I was going to ask you, in terms of navigation, do you always use navigation for your surgery as well as do you like navigating instruments like navigating microdebriders and those kinds of tools as well?
[Dr. Amber Luong]
Yes. For allergic fungal-- Well, number one, we're at an academic center. I think we probably tend to use the navigation probably more frequently than in private practice. I don't think that you have to use the navigation for all of your cases. Allergic fungal is one of those that I use it, even if I wasn't teaching, more often than not, just because of some of those characteristics we talked about, some of the areas where the skull base can be really thinned out, the unusual anatomy caused by the expansion of the sinus cavities.
I will more often use navigation. I don't like the microdebrider so much in terms of all of my dissections. I think that's just the way I trained. I trained more with the sharp instruments and sharp dissection and using my microdebrider more for the soft tissue. That being said, I think that there's definitely a role for using a microdebrider and it can be a lot quicker. It's just that I enjoy the dissecting aspect of it. In allergic fungal, sometimes that's not even a possibility. There, the microdebrider is more helpful because all those partitions are gone. All you're dealing with are polyps anyway. There's nothing for me to sharply dissect.
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Curbing Peri- and Post-Operative Inflammation with Steroids
Allergic fungal rhinosinusitis treatment is primarily surgical. Judicious use of steroids supports surgical treatment and reduces risk of recurrence. While Dr. Luong does not start patients on steroids when they first present, she does prescribe a course of prednisone 40mg in the 3-4 days leading up to surgery to reduce bleeding intraoperatively. After AFRS surgery comes a short steroid taper tailored to each patient’s exam at the post-op visit that same week. A typical taper could consist of 30, 20, then 10 milligrams of prednisone, each for three days in the nine days following surgery. During sinus surgery she places steroid-eluting stents to maximize local effects of this medication.
[Dr. Amber Luong]
40 milligrams of prednisone, three to four days before surgery, and then you do your surgery. Then after that, so for me, I don't do that perioperative steroid. However, after surgery, I will do that steroid, but I don't do it as high as I used to. I'll do more of 30 milligrams, three days, 20 milligrams for three days, 10 milligrams for three days. If it was really bad, maybe I might do a 40 milligram and a little bit longer, three or four days. Some of that is just clinical, like how long I want to expose them to steroids. I'll see them at that first week and decide how they're doing, and then see if we can start then adding on the topical steroids
For allergic fungal patients, as well as a lot of my eosinophilic patients, I will put in at the time of surgery, a device that releases steroids locally because we know that the surgery in of itself causes a lot of inflammation. I like the idea of adding steroids locally there. For allergic fungal, I will still add on the oral steroids because it's probably not enough, but I taper them off pretty quickly, as I sort of alluded to. I don't do the month-long steroids. That has worked out really well. Some of these steroid delivery devices have an open matrix. That would be a concern for me, right? If I've went through and spent all this time opening up the sinus cavity and then putting in something that may block off the sinus cavity. I like the fact that these various different delivery systems have an open matrix. I feel comfortable putting it in there. That way it helps handle the inflammation that I may have caused without blocking some of the mucin and allowing the patients to start irrigating immediately after allergic fungal rhinosinusitis surgery.
Post-Operative Care for Allergic Fungal Rhinosinusitis Patients
Post-operative management of allergic fungal rhinosinusitis relies on saline rinses to decrease risk of mucus buildup. After AFRS surgery, Dr. Luong starts her patients on twice-daily saline sinus rinses containing budesonide and mupirocin. For cases where a steroid-eluting sinus stent was placed, she prescribes a ten-day course of Duricef 500 mg to reduce risk of staph colonization. Once patients master their sinus rinses and symptoms subside, she tends to see patients annually.
[Dr. Ashley Agan]
How do you prescribe your Mupirocin and budesonide irrigations? How do you tell them as far as, how do you get the ointment to dissolve and how much are you putting in there? Are you just doing the Pulmicort Respules or, can you explain that part?
[Dr. Amber Luong]
For the budesonide, I use the Pulmicort Respules. It's two milligrams in two ccs, I believe is my dosing. I'll have to go back in because now I'm confused because they've been having to change it. Ultimately, it's one Respule in one bottle of 240 cc. One Respule, one bottle for my Budesonide, half the bottle on one side, half the bottle on the other, and ideally twice a day. Then for my Mupirocin, if you're lucky enough to find a compounding pharmacy, we usually will try to do 200 milligrams of mupirocin powder that dissolves into the saline. Oftentimes, because it's off-label use, and so make sure patients know it is off-label use, sometimes we get pushback from the insurance. Then we are able to find, sometimes have them cover 20 milligrams of Mupirocin powder because it does dissolve a lot easier. Otherwise, we are stuck with the Bactroban ointment and one tube in the ointment and just warming it up slightly, mixing it. Obviously, it can't be too hot, otherwise you can't get it. I have them warm it up slightly, try to get as much in, and then once it's at room temperature to irrigate their nose. In that situation, I don't know if it's more for me or for them that it's really working.
[Dr. Gopi Shah]
Gosh. One last question about antibiotics. Are you doing ever three to six weeks of an anti-staph oral antibiotic? Is that in vogue, out of vogue? Nobody ever did it and I made it up. Is that still happening?
[Dr. Amber Luong]
I think that's when like things fail. I wouldn't say that that's the first line, but for allergic fungal, I haven't used it. I think you're alluding to like doxycycline or some of the macrolides, people talk about macrolides. The macrolide where it's a longer course, that's more probably for your CRS without nasal polyps that people describe that population that it may play a role. Then when other things fail, people will use the doxycycline for your CRS with nasal polyps. The data is not very good. That's where we're trying to explore options that are typical go-to treatment options don't work, but I don't think the data is very good. I think that that's why when you go to guidelines, all of those things are like options and weak data.
[Dr. Gopi Shah]
For the patients doing their budesonide rinses, is that forever? Is that patient dependent on how they're looking when them? How do things usually happen post-op? What's the rest of the story after surgery?
[Dr. Amber Luong]
I think that with their life, with me, it's forever. Ideally, I'd like to get them to a saline spray and a nasal steroid spray. I'm not naive to realize that most patients after probably around 10 years, they start tapering off and maybe they'll come see you once a year. Then they'll tell you, "Doc, I have to be honest, I use it like a couple of times a week. Every once in a while, I may use a steroid spray," whatever. Then you look in their nose and then you have to decide and you tell them, give them the feedback, "Hey, this has worked and obviously this has worked for you. Do whatever you're doing because it's working."
Dr. Amber Luong
Dr. Amber Luong is the vice president of the American Rhinology Society and a professor of otolaryngology at McGovern Medical School in Houston, Texas.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2022, October 11). Ep. 73 – Allergic Fungal Rhinosinusitis [Audio podcast]. Retrieved from https://www.backtable.com
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