Allergic Fungal Rhinosinusitis

Transcription

1 Allergic Fungal Rhinosinusitis My Published Experience Prof. Surayie H Al Dousary Professor of Rhinology Rhinology research Chair Director KSU Rhinology fellowship Program Director KSU Rhinology Unit Chairman King Saud University (KSU) Riyadh, Saudi Arabia

2 KSU Subspecialty and Research Development Before 1997 OTL Academic PGT Team 1997 subspecialty KAUH; Cochlear Implant Team & CAS Rhinology Team 2010 Rhinology research chair (KSU research chairs projects) 2018 Five KSU Fellowship subspeciality. annual research projects plan at the first 3 months of the training (Research Unit Director) All of you are invited to participate in these 5 research projects groups

3 Bent and Kuhn Diagnostic Criteria 94 Major Type I hypersensitivity Nasal polyposis Characteristic CT findings Eosinophilic mucin without invasion Positive fungal stain Minor Asthma Unilateral disease Bone erosion Fungal cultures Charcot-Leyden crystals Serum eosinophilia

4 My publications AFRS CRS AND AFRS In collaboration with KSU Residents Fellows Teaching staffs Gent upper airway lab prof

5 Demographic, Clinical and Radiological Features

6 Unilateral / Bilateral AFS (20:39)

7 Histological and Microbiological Features

8 Surgical Treatment Goals Complete extirpation of all allergic mucin and debris Permanent drainage and ventilation of the affected sinuses Postoperative access to the previously diseased areas.

9 Conclusion Geographic diversity existence regarding most commonly implicated fungi in AFS. Different Diagnostic Criteria AFS & AFS Like Need of Clinical Basic Research Multicenter Collaborative Effort Data Center Data Collection Data Analysis Business Intelligence

10 Computer-aided endoscopic sinus surgery: a retrospective comparative study 60 patients (30 and 30) 66.7% had CRS and 33.3% had AFS. Primary surgery 61.7% and revision surgery 38.3% of cases. CAS group included 93.3% extensive disease and 40% with bone erosions and extension,, Non-CAS group included 80% extensive disease and 23.3% bone erosions and extension The average operative time was approximately 13 minutes greater in the navigation group, Recurrence rate 36.7% in the non-cas group and 16.7% in the CAS group Two Patient had exposures of orbital fat in the non-cas group; No complications in the CAS group Ann Saudi Med 2010; 30(2): Jamil Al-Swiahb, Surayie Al-Dousary

11 Computer Assisted Surgery Available in KAUH since 1997 It is Assistance Check the accuracy before and during surgery Most of the Inaccuracy is CT Protocol based

12 Results Average time of surgery in CAS group was 3 hour and 26 minutes Average time of surgery in non CAS group 3 hours and 13 minutes Recurrence rate in non computer assisted group 11 patients(36.7%) Recurrence rate in computer assisted group 5 patients (16.7%)

13 Conclusion CAS improves the confidence of the surgeon by confirming position within challenging anatomic fields. The major drawback to using image-guided systems was the increased operative time which improve with advance in the technology.

14 Paranasal sinus wall expansion, thinning and erosion associated with Allergic Fungal Sinusitis. AFRS some time expansion, thinning and erosion of the paranasal sinus (PNS) wall can be seen in these cases. 25% of patients were deemed to have bone erosion ascertained by CT scan and/or MRI. 42 % showed intraorbital extension 33% had intracranial extradural extension. All patients were treated by endoscopic sinus surgery and medical treatment. Saudi journal of Rhino- Laryngology Head and Neck Surgery Vol 13 No2 July 2011

15 Paranasal sinus wall expansion, thinning and erosion associated with Allergic Fungal Sinusitis. Saudi journal of Rhino- Laryngology Head and Neck Surgery Vol 13 No2 July 2011

16 Intracranial Extradural Extension No intracranial complication associated with AFRS Even though there is variable skull base defect There is intracranial, extra dural extensions

17 Surgical Treatment

18 Post Operative Medical treatment

19 Conclusion Paranasal sinus wall expansion, thinning and erosion is a well known feature of the AFRS which can lead to a serious complication if not diagnosed and treated properly. CT Scan imaging of PNS is critical to diagnose and assess the erosion and its extent. clearing the sinuses from the inflammation.

20 Allergic fungal sinusitis in children in Saudi Arabia. Saudi Med J Nov ;28 (11): Jamil N Al-Swiahb, Ahmed Al-Ammar, Surayie H Al-Dousary,

21 Patient Population All patients are immunocompetent. Diagnosed as cases of AFRS if they had 4 or more from Kuhn and Swain diagnostic criteria. 25 patients with the feature of AFRS 14 male and 11 female Age range 8-16 years All are Saudi, belonging to the central region The duration of symptoms at time of presentation was 3 months to 2 years.

22 The most common clinical features Nasal obstruction 24 (96%) Nasal polyposis (grade 3-4) 22 (88%) Deviated nasal septum 17 (68%) Allergic rhinitis 16 (64%) Snoring 15 (60%) Purulent nasal discharge 13 (52%) Mouth breathing 13 (52%) Hyposmia 13 (52%)

23 Results Postnasal discharge 9 (36%) Bronchial Asthma 9 (34%) Headache 7 (28%) Orbital proptosis 7 (28%) Nasal polyposis (grade 1-2) 3 (12%) Visual problem 3 (12%) Cheek swelling 3 (12%) Ear symptoms 5 (20%)

24 Clinical presentation dose not correlate with CT findings

25 Extensive Disease with Minimal Symptoms and Signs

26 Radiological findings Maxillary sinus opacity 25 (100%) Ethmoid sinus opacity 25 (100%) Frontal sinus opacity 12 (48%) Sphenoid sinus opacity 16 (64%) Sinus wall Expansion 15 (60%) Sinus wall erosion 7 (28%) Intraorbital extension 6 (24%)

27 Conclusion Presentation is late and Extension rate is higher The clinical presentation usually dose not corelate with the radiological findings AFRS can be found incidentaly in children population 44% had recurrence

28 Ophthalmic Manifestation of Allergic Fungal Rhinosinusitis Prof. Surayie Al Dousary, Prof. Fatmah Al Anazy 16 % of the AFRS patients had orbital manifestation The most common ophthalmic presentation was Proptosis (83%), Epiphora (33%), Ophthalmoplegia (33%), Diplopia (22%), Visual loss (13%), and Subperiosteal abscess (6%). CT sinus scans showed that 62% of patients had erosion of the lamina papyracea, 16% presented with bilateral erosion of lamina papyracea. 61% had right-sided predominance. 24% had extension to the orbital or brain. Ophthalmic Manifestations of Allergic Fungal Sinusitis Saudi journal of rhino- laryngology head and neck 2011

29 Orbital Extension & Dacrocystis

30 CONCLUSION Although orbital complications of AFRS are uncommon, they can be serious and necessitate immediate surgical intervention. Ophthalmologists and otorhinolaryngologists should be familiar with these complications.

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32 CT SCAN PRE OP & POST OP FESS & Post OP Steroids Itraconazol 200 mg BID for 6 Months

33 Ophthalmic manifestation of the paranasal sinus disease; a clinical grading system PNS Diseases and Eye Manifestations Acute sinus infection Secondary orbital inflammation Chronic sinus inflammation Resulting in expansion and erosion of the surrounding structure Sinus Mucoceles Orbital Extension Local Immunological reactions Orbital involvement nt Forum Allergy Rhinol Jul-Aug;2(4): doi: /alr Epub 2012 Mar 12. Ophthalmic manifestations of paranasal sinus disease: a clinical grading system

34 Chandler s Classification Chandler divided his patients into five groups: According to the Anatomic Location and the Type of the Infections Group I and II is Cellulitis. Preseptal and Orbital Cellulitis Groups III, IV and V are all Abscesses. Subperiosteal, Orbital and Cavernous Sinus Thrombosis

35 AFRS Ophthalmic Manifestation Varies from Proptosis

36 AFRS and Nasolacrimal Duct Obstruction

37 AFRS May Present With Visual Loss

38 AFS Ophthalmic Manifestation Carter et al, Allergic fungal sinusitis, American Journal of Ophthalmology Vol. 127, NO. 2

39 Grading according to Ophthalmic Involvement Grade I Ophthalmic Involvement Patients with anatomical disturbance II III IV Patients with mild ophthalmic functional disturbance Patients with orbital infection Patients with visual impairment

40 Group I Grade I Presentation Diagnosi s Mangem ent Outcome Anatomical disturbance # 15 (36%) FU 1-2 y Proptosis Bilateral proptosis Pts=10 Unilateral proptosis Pts=5 All pts Nasal polyposis and orbital wall expansions AFRS Pts=9 60% CRS Pts=6 40% Ethmoid Mucocele Pts=1 Functiona l endoscopi c sinuses surgery (FESS) Resolution of proptosis

41 Group II Grade II Presentation Diagnosis Management Outcome Functional Involvement # 11 (26%) FU 1-2 y Epiphoria Pts=5 (45%) Diplopia Pts=3 (27%) Ophthalmoplegia Pts=2 (18%) AFRS Pts=6 55% CRS Pts=3 27% Mucocele Pts=2 (18%) Functional endoscopic sinuses surgery (FESS) Ptosis Pts=1 (9%) All patients demonstrated lamina papyracea erosion/intra-orbital extension; 4 (36%) of them additionally showing skull base erosion. Resolution of Epiphoria and diplopia and partial improvem ent in ophthalm oplegia and ptosis.

42 Group III (Chandler s ) Grade Presentation Diagnosis Mangement Outcome III Orbital Infection # 11 (26%) Follow up 3M-2y Orbital cellulitis associated with epiphoria and proptosis Pts=6 (36%) pre septal-cellulitis Pts=3 (27%) (whom 2 had (dacrocystits Abscess pts=2 (18%) (1 each with orbital abscess and subpereostial abscess) AFRS Pts=3 CRS Pts=5 Acute rhinosinusitis Pts=3 AFRS and CRS FESS and orbital abscess drainage when indicated in addition to antibiotic therapy) Acute rhinosinusitis FESS and responded to antibiotic therapy. Resolution of orbital infections

43 Group IV Grade IV Presentation Diagnosis Mangement Outcome Visual Im#pairm ent # 5 FU 1M 2 y Blindness Pts=2 (1 bilateral and 1 unilateral blindness with orbital infection) Unilateral visual impairment Pts=3 AFRS Pts=3 Acute sinusitis and fulminate mucormycoses Pts=1 Frontal muococele Pts=1 All patients FESS and appropriate antibiotic treatment Patient with frontal muococele undergoing surgery for reconstruction of the orbital roof with a bicoronal flap All patients with visual impairment regained their vision after surgery and medical treatment Pts with bilateral blindness (mucormycose s ) died from cerebral extension (within 4weeks)

44 Clinical Grading Summary Grade Presentation Number ARS Muc ocel AFS CRS Proptos is Orbit Infectio n Visual Impairme t Follow Up I Anatomical Disturbance Proptosis 15(36%) y II Functional Involvement Epiphoria Diplopia Ophthalmoplegia Ptosis 11(26%) y III Orbital Infection IV Visual Impairment Orbital cellulitis, Pre septal-cellulitis Orbital abscess Subpereostial abscess Visual Impairment, blindness 11(26%) 5(12%) M -2 y 1M-2 y

45 Sinus Pathology Causing Ophthalmic Manifestation Allergic Fungal Sinusitis (50%) Chronic Rhinosinusitis (36%) Acute Sinusitis (10%) Mucocele in (4%)

46 Ophthalmic Manifestation Grade % Proptosis G I (36%) Functional involvement G II (26%) Orbital infection G III (26%) Visual impairment G IV (12%).

47 Conclusion This is an easy to apply Clinical grading system that doesn t require Imaging Encompass Acute orbital infection and chronic Sinogenic pathology causing orbital manifestation. Radiologic findings does not correlate well with clinical severity The main cause of orbital complications is chronic Paranasal sinus disease in (74 %) of the cases. The urgency of intervention proportional to the severity of the disease and to the proposed clinical grading system

48 Allergic fungal rhinosinusitis more than a fungal disease? Upper Airway Research Lab Gent University Belgum 17 AFRS Pts 13 CRSwNP Pts and 12 Control Ptsv Fungi can function as allergic antigen lead to IgE mediated reaction Aspergillus sp will induce IgE Specific antibody They can act as superimposed to CRS The Massive elevation of the total IgE can t be explained Superantigen and TH2 biased amplify the production of the total and specific IgE and IgG B and T cells polyactivation Recent study showed S Aereus more prevelant in the AFRS group

49 Total and specific IgE and IgG The SE-IgE correlate well with totlal IgE which is present in the sera of all the AFRS patients The m3-ige does not correlate well with totlal IgE S Auereus synergize the Asperigillus effect by the superantigen and the enterotoxin leading to total ige elevation Clin Transl Allergy. 2013; 3(Suppl 2): P15. Published online 2013 Jul 16. doi: / S2-P15

50 Serum total and specific IgE Concentration(median=IQR) of patients with AFRS versus non-afrs CRSwNP and Control Subjects

51 In situ hybridization (PNA-FISH) of a biofilmlike structure on the epithelium of paranasal sinus mucosa in a patient with AFRS

52 AFS infratemporal fossa involvement Here we report our experience in AFRS with unusual infratemporal fossa (ITF) involvement Our aim is to draw the attention of rhinologist to such AFRS presentation, management plan and outcome in such cases

53 Clinical and Radiological Findings

54 AFRS Pre op- Intra op Post op

55 Conclusions AFRS extension in to the ITF is twice more frequent than intra cranial and than intra orbital extension. ITF extension in children most likely due to expansion of the non fused suture line ITF extension can be easily endoscopically washed out All patients had no ITF recurrences post operative.

56 Has been accepted for publication Psychometric Arabic Sino-nasal Outcome Test-22:validation and translation in chronic rhinosinusitis patients Annals of Saudi Medicine 2018

57 EPOS 2012 Arab Consultants Working group

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