Treatment

Successful control of AFS involves complementary medical and surgical approaches. Unfortunately, recurrence rates are high; therefore, the goal is to extend the disease-free interval between revision surgeries.

Oral corticosteroids have an important role in the management of this disease. They are often started preoperatively, at a dose of 60 mg of prednisone for three days, followed by a two-to-four-week taper. This regimen can improve surgical visibility and reduce intraoperative bleeding by shrinking the polyps. Some surgeons, on the other hand, prefer to wait for several weeks after surgery to administer steroids, to avoid interference with postoperative healing. The use of perioperative oral steroids appears to increase the disease-free interval and time to recurrence (9).

Surgical treatment involves conservative endoscopic removal of nasal polyps and inspissated allergic mucin. This procedure requires a sinus CT scan to inform the surgeon about anatomic variations. Many centers now use image guidance systems that allow realtime three-dimensional intraoperative localization. This is particularly useful for nasal polyps and even more so for revision polypectomy where normal sinus landmarks may be absent due to previous procedures. Microdebriders are very efficient for resection of nasal polyps but because of their potential to damage surrounding structures, they are used with image guidance. The mucin of AFS can be difficult to remove. Simple lavage is usually insufficient and microdebriders facilitate removal.

After surgical opening of the sinus cavities, patients continue twice-daily nasal irrigation and topical nasal steroids. Doses up to three to four times the usual for allergic rhinitis have been used. Office endoscopy with debridement of allergic mucin can prolong remission. Monitoring of total serum IgE can be helpful in the followup of these patients. Increasing total serum IgE often precedes the need for a return to the operating room.

Long-term oral corticosteroid therapy can effectively suppress this disease; however, it is fraught with side effects. Patients need to be monitored for diabetes, osteoporosis, and cataracts. The oral steroid protocol used by Schubert and Goetz is detailed in Table 2.

Immunotherapy may have a role in AFS. Immunotherapy works by inducing specific IgG "blocking antibody." Patients with AFS, however, already have elevated IgG and IgE; therefore, immunotherapy was initially thought to be contraindicated. Mabry demonstrated an absence of ill effects and possible improvement in patients receiving immunotherapy with fungal antigens, and it is now considered accepted practice to offer patients this treatment (Table 3). After formal testing for common allergens and all available fungal antigens, definitive immunotherapy is initiated. This can be continued for a three-to-five-year period. Furthermore, patients also are instructed on environmental modification and mold avoidance. This approach reduces the need for maintenance systemic steroids and revision surgery (2).

Antifungal therapy has been proposed, and oral itraconazole and voriconazole have good in vitro activity against dematiaceous fungi, but they have not been shown to be useful and are generally not recommended.

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