BackTable / ENT / Podcast / Episode #73
Allergic Fungal Rhinosinusitis
with Dr. Amber Luong
In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak about allergic fungal rhinosinusitis with Dr. Amber Luong, vice president of the American Rhinology Society and professor of otolaryngology at McGovern Medical School.
BackTable, LLC (Producer). (2022, October 11). Ep. 73 – Allergic Fungal Rhinosinusitis [Audio podcast]. Retrieved from https://www.backtable.com
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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.
Allergic fungal sinusitis (AFS) is a subtype of chronic rhinosinusitis with nasal polyps that present with allergic inflammation against fungal antigens. It has some unique features, such as very expanded sinus cavities and a thick, sticky mucin. Oftentimes, patients have an allergy sensitivity and elevated IgE levels in the thousands. Diagnosis is usually made based on the Bent and Kuhn Classification, which is based on clinical/phenotypic criteria. However, Dr. Luong notes that AFS can have geographically diverse presentations. She has noticed that there is a higher AFS prevalence in the South because of the more hot and humid weather. Looking towards the future, she predicts that molecular pathophysiology will be more important in diagnosis, as distinction between the AFS endotypes can serve as targets for therapy. Her research laboratory works on finding these molecular targets.
Next, the doctors discuss typical AFS patient presentations. Dr. Luong usually sees young patients in their 20s with unilateral disease. If they have bilateral disease and other symptoms, it is most likely cystic fibrosis, not AFS. Additionally, AFS patients will have expanded sinuses on CT that may cause a mild headache. Dr. Shah adds that in severe cases, smell and vision loss is possible. However, AFS generally has a low symptom burden because patients get used to the symptoms. Dr. Luong notes that she usually only orders a CT scan. No MRI is needed unless other complications are noted (vision loss, meningitis, skull base / cranial nerve invasion). She orders labs like CBC with differential and total IgE levels.
Next, she shares surgical pearls for treating AFS. She believes that the first surgery is critical to controlling the disease and preventing recurrence. She performs a full FESS on the impacted side and inserts a PROPEL stent that releases steroids locally. Because the sinuses are difficult to clear, she uses angled scopes, warm saline, and the hydrodebrider to complete this task. Although the microdebrider with navigation can be helpful, she doesn’t really use it.
Finally, she shares her steroid regimen. She prescribes at least 40 mg of prednisone in adult patients 3-4 days before surgery. Postoperatively, she prescribes an oral steroid taper starting at 30 mg and decreasing the dosage by 10 mg each week. Additionally, she gives her patients a post-operative nasal rinse that consists of mupirocin and budesonide. She emphasizes the importance of making the postoperative regimen as easy as possible to ensure daily compliance. Finally, the doctors discuss trends in AFS patient follow up.
Again, luckily, these patients, most of them do great with a good surgery upfront. I think that if you are lucky enough to catch someone with the initial presentation of allergic fungal, I would say that first surgery is really critical. If you are not set up to have the instruments, because there are some special instruments, some special frontal instruments, some of these and more expanded sinus instruments, I would say it's probably better for you to refer it on to a group that may just do more sinus surgery than you may. It's not because you're necessarily going to be unable to do it. It's just that you haven't invested in the instruments to help you get all that mucin. In my experience, that first shot, that first surgery is so critical because once they get down the road where they have a recurrence almost within a month after that initial surgery, it becomes way more challenging to get them under control.
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