1. AFRS: Current Approaches to Postoperative Management
Bradley F. Marple, MD
Professor
Dept. of Otolaryngology
Univ. of Texas Southwestern at Dallas

2. Potential Role for Fungus in CRS
Fungal allergy
Invasive Fungus
Fulminant
Indolent
Granulomatous
Non-invasive fungus
Mycetoma
Saprophytic growth
AFRS
EFRS
Allergic Fungal Rhinosinusitis
Points to make:
Fungus is currently considered a viable candidate as promoter of CRS
Fungus is recognized to interact in a number of ways
Range is wide: In some cases fungus can be present within the nose without contributing to disease.
Saprophyte
EFRS
Marple, Laryngoscope 2001;111:

3. Clinical Observations
Concerning AFRS
Need a clear picture of the disease that is at the center of this talk

4. Radiographic Characteristics: Bone Erosion
Allergic mucin mucocele
Associated obstructive sinusitis
Heterogeneous appearance3 Ca
Chelated Fe, Mn
Mukherji1
Reviewed 45 AFRS CTs
Bone erosion - 20%
Nussenbaum, Marple2
Reviewed 142 AFRS CTs
Histology - 0/142 demonstrated invasion
The most notable aspect of the disease is the radiographic characteristices
1Radiology 1998; 207:417-22
2Oto HNS 2001;124:150-54
3Zinreich et al. Radiology 1988; 169:

5. Clinical Presentation: Mucin
Mucin is the hallmark of the disease
As a brief review, those patients with AFRS present in a clinically characteristic fashion. Hallmarks of the disease in most cases are polyps, while the presence of gross mucin is present in all cases.

6. Allergic Mucin Gross findings - indistinguishable from ABPA Histology
Thick viscosity
Tan, black, green
Histology
Non-invasive fungus
Grocott
Giemsa
PAS
Eosiniphils
Charcot-Leyden Crx

7. Diagnostic Criteria Bent and Kuhn Cody Allphin Lowry, Schaefer
Polyposis
CT findings
Eosinophilic mucus; no fungal invasion
Gell & Coombs type I hypersensitivity
JACI, Oto-HNS 2004
Eosinophilic mucin
Histo – non invasive fungus
Fungal specific IgE
Cody
Allphin
Lowry, Schaefer
deShazo, Swain
For the purposes of this presentation it is important to point out that up to a point there was no doubt of the association of allergy with AFRS
Bent, Kuhn, Oto-HNS 1994;111:580-88
Meltzer, Hamilos, Hadley, Lanza, Marple, et. al. JACI 2004;114:S155-S212.

8. Eosinophilic Fungal Rhinosinusitis
Let us compare and contrast AFRS with another proposed clinical entity defined by the presence of both eosinophils and fungi…..EFRS

9. Mayo Experience – Evolution of a Pathogenesis
Ponikau – Improved ability to identify nasal fungus
94/101 clinical diagnosis of AFS
100% controls with fungus
Allergy – no difference from general CRS population
Proposed term “EFRS”
Shin, Kita – PBMC + Alternaria
IL-5, IL-13, IF-g
Taylor – Fluorescein-labeled chitin stain
Wei – Chemotaxis of eosinophils in presence of tissue/mucin of CRS
Demonstrates chemoattractant effects
Ponikau – Ampho B irrigation
38/51 symptoms improved
45 with prior surgery
35% endoscopically cleared
No control group
The story of EFRS begins in 1999 with the publication of the original article from the Mayo, which demonstrated that with sufficiently sensitive culture techniques fungi could be recovered from virtually all noses, diseased or not. Moreover, when the mucin from surgical patients with CRS was examined, 93% satisfied their histologic diagnosis of AFS. However, when these cases were studied for allergy, it did not vary from that which is recognized in the general CRS population. Given the lack of allergy, the name EFRS was proposed.
That is all well and good, but what was really interesting was when Kita demonstrated that PBMC were exposed to Alternaria they produced significantly greater amounts of cytokines IL-5, IL-13, and IF gamma. This, in many’s opinion, is the most compelling piece of information regarding this that has been produced. Unfortunately, these data have yet to be published in a peer-reviewed fashion.
Other studies by the Mayo have described their techniques for the resolution of histologic staining for fungus, and have demonstrated in a boyden chamber in vitro chemoattraction of eosinophils to mucus and tissue of patients with CRS.
These studies have culminated in an uncontrolled study of Amphoterocin B irrigations for the treatment of CRS in which symptoms improved in response to treatments in 38 of 51, and endoscopic clearance in 35%.
Ponikau. Mayo Clin Pro. 1999;74:
Shin. JACI (abstract). Shin SH, Kita H et al . AAAAI NY, March 6, 2002
Taylor. Oto-HNS 2002;127:
Wei. Laryngoscope 2003;113:
Ponikau. JACI 2002;110:

10. Why the Difference? What are we calling “mucin”?
EFRS
AFRS
GMS
It is interesting that when we find easily identified mucin, the GMS stains are effective.
On the other hand, GMS stains are more frequently negative in the absence of easily recognized mucin, necessitating the use of chitin immunofluorenscence.
The real question is whether these issues play a role in the interpretation of information?
GMS
Chitin
GMS
Courtesy of Ponikau

11. Impact of Clinical Findings upon Immunologic Data67 20 87
In this slide, the I have plotted the immunologic findings produced by the Ponikau method versus all other papers that were used for this presentation. Skin or in vitro analysis for fungal antigens demonstrated differences. I applied no statistics, however.
179
179
Marple, presented Maryland CRS meeting 2003

12. AFRS vs EFRS: Why the Difference?
Are we looking at the same disease?
Patient selection Narrow Broad
Definition of allergic mucin Gross Microscopic
Incidence of atopy Near 100% Same as CRS
Specificity vs sensitivity Too specific Too sensitive
Marple, ARS Newsletter 2002;21

13. Fungal Specific Humoral Response
Background
Literature to 2004:
Fungal allergy plays central role in pathogenesis of AFRS
Fungal specific IgE is a critical marker for AFRS
Inconsistent definitions for AFRS
Pant/Wormald
Sub-classified CRS in an attempt to better understand the role of humoral responses in the pathogenesis of the disease
Pant H, Laryngoscope 2005;115:

14. Fungal Specific Humoral Response
Design
86 study subjects were enrolled
Sub-classified based upon following criteria
Presence of macroscopic eosinophilic mucin
Presence of fungal allergy
Histologic presence of fungi in eosinophiloc mucin
Cultures obtained from mucin
Serologic tests
Fungal specific IgE
Fungal specific IgG, IgM, IgA
Pant H, Laryngoscope 2005;115:

15. Fungal Specific Humoral Response
spIgE (Alternaria alternata and Aspergillus fumagatus) failed to differentiate
EMCRS from controls
Subsets within EMCRS
Culture results only partially matched those spIgE
Pant H, Laryngoscope 2005;115:

16. Fungal Specific Humoral Response
Results
Alternaria alternata and Aspergillus fumigatus IgG3 marked the presence of EM (p=0.002, 0.004)
spIgG3
Distinguished EMCRS from all other controls
May signify pathogenic significance of IgG3
Alternaria spIgG3
Pant H, Laryngoscope 2005;115:

17. Types of Fungal Sinusitis
Invasive
Fulminant
Indolent
Granulomatous
Non-granulomatous
Non-invasive
Fungal Ball (Mycetoma)
Saprophytic growth
Eosinophilic Fungal Inflammation
IgE – dependent fungal inflammation
Classic AFRS
Non IgE-dependent fungal rhinosinusitis
Eosinophilic Fungal Rhinosinusitis (EFRS)
Perhaps rather than pitting the two diseases against one another, it would be more appropriate to classify these diseases in a manner that will be recommended in an upcoming consensus paper generated by representatives of the allergy and otolaryngology communities. This is based upon the prevailing recognition of the difference between the two diseases.
Meltzer, Hamilos, Hadley, Lanza, Marple, et. al. Rhinosinusitis: Establishing Definitions for Clinical Research and Patient Care JACI 2004;114:

18. 2006: Role of Fungus and Allergy in AFRS
AFRS is a distinct clinical entity that exists as a subset of CRS and is strongly associated with
Fungus
Allergy
The central role of allergy in the pathogenesis of AFS is now in question
But IgE-mediated sensitivity remains important identifier
It is reasonable to direct therapy based upon the presence of allergy and fungus
Evidence-based data is limited

19. AFRS: Treatment Fungus Surgery Immunomodulation Close follow-up AFS
Antifungals
Fungus
Surgery
Complete removal of fungal antigen
Tissue sparing
Immunomodulation
Perioperative steroids
Immunotherapy
Close follow-up
Saline irrigation
Office visits
Surgery
Irrigation
Proliferation
Antigen Exposure
Decreased Drainage
Decreased Ventilation
Stasis (Mucin)
AFS
Immune Response
IgE/non-IgE
Mast Cell Degranulation
Mucosal Edema
Inflammation
Immunotherapy
Steroids
Marple,Mabry, AJR 1998:12;

20. Treatment Principles I. Elimination of Fungal Antigen (Surgery)
II Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic
Marple, Laryngoscope 2001;111:

21. Goals of Surgery Complete extirpation of mucin
Fungi stimulate inflammation
Permanent drainage & ventilation
Preserve mucosa
“Complete, but conservative”
Post-operative access
Surveillance
Irrigation
Marple,Mabry, AJR 1998:12;

22. Postoperative Recidivism
Bent - Near 100% recurrence in absence of medical treatment
Kupferberg - 19/24 patients recurred after d/c of steroids
Schubert - 67pts
Steroids for >2 mo. - 35% 1yr
Steroids for <2 mo. - 55% 1yr
Marple, Mabry - 42pts
Immunotherapy - 10% mo.
We are going to come back to this point, but what is important in this slide is that in the absence of further treatment the rate of disease recurrence is unacceptable high. Do not go into
Allergy Asthma Proc 1996;17:259-68,
Oto-HNS 1997;117:35-41,
J Allergy Clin Immunol1998;102: ,
Am J Rhinology 2000;14:223-26

23. Treatment Principles I. Elimination of Fungal Antigen (Surgery)
II Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic

24. Immunotherapy for AFS: Theory
Originally contraindicated
Analogies to ABPA
Theoretically contraindicated in treatment of ABPA “because of the uncertainties involved”1
Specific IgG production may elicit immune complex reaction (G&C III)
Ferguson2 - concluded no effect
7 AFS patients
2 responded (surgery)
5 no response
1Middleton & Reed, pp , 1993.
2Ferguson, Abstract AAOA, 1993.

25. Could IT be used as a part of a comprehensive plan?
Surgery
Remove antigenic load!
Allergic evaluation
RAST (or skin test)
3 most relevant fungal antigens
Non-fungal antigens
Skin test (or RAST) for additional fungi
Allergy treatment
Treat for all positive reactors
Do not treat only cultured fungus
Treat non-fungal reactive antigens
Mabry, Marple, Mabry Oto-HNS 1999;121:252-4

26. Cross-sectional study of 22 AFS pts Evaluation
Treatment of AFS: a comparison trial of postoperative IT with specific fungal antigens1
Cross-sectional study of 22 AFS pts
2 groups matched for preop severity of disease (CT&PE)
Similar surgery
11 tx’d with IT
11 no IT
Evaluation
Regular exam and endoscopic staging (Kupferberg)
Chronic Sinusitis Survey (Glichlick & Metson)
1Folker, Marple, Mabry, Mabry, Laryngoscope 108: , 1998

27. Treatment of AFS: a comparison trial of postoperative IT with specific fungal antigens1
Corticosteroids
IT group
Systemic - 0%
Non-IT group
Systemic - averaged 2 courses per year
Follow-up
Overall mean f/u 33 mos.
IT group
Mean - 30 mos.
Range mos.
Non-IT group
Mean - 35 mos.
Range mos.
1Folker, Marple, Mabry, Mabry, Laryngoscope 108: , 1998

28. Endoscopic Mucosal Staging
Folker, Marple, Mabry, Mabry, Laryngoscope 108: , 1998

29. Chronic Sinusitis Survey
p<0.05
Folker, Marple, Mabry, Mabry, Laryngoscope 108: , 1998

30. Treatment Principles I. Elimination of Fungal Antigen (Surgery)
II Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic

31. Corticosteroids: Rationale
Concept originates from the treatment of ABPA
Anti-inflammatory
Immunomodulation
Systemic
Used in some form for all patients with AFS
Topical
Standard therapy
No published evidence of effect in AFS
Effect demonstrated in NP

32. Corticosteroids Bent1 Schubert2 - 67 pts Corticosteroids < 2mo
Universal recurrence of AFS in following discontinuation of corticosteroids
Schubert pts
Corticosteroids < 2mo
55% recurrence at 1yr
Shorter time to recurrence
Higher total IgE
Corticosteroids > 2mo
35% recurrence at 1yr
Longer time to recurrence
Lower total IgE
1Bent, Kuhn, Allergy Asthma Proc 17:259-68, 1996
2Schubert, Goetz, J Allergy Clin Immun 103: , 1998

33. Treatment Principles I. Elimination of Fungal Antigen (Surgery)
II Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic

34. Systemic Antifungals Denning Ferguson Rains Kennedy May limit
Use of itraconazole for ABPA
Decrease in total IgE
Decrease in systemic corticosteroid use
Ferguson
Limited available data
Potential drug related morbidity
Cost of treatment
Rains
Safety of itraconazole
Kennedy
Terbenifine offered no benefit to the treatment of CRS
May limit
usefulness of
therapy
1Denning, et al, Chest 100:813-19, 1991
2Ferguson, Arch Otolaryngol Head Neck Surg 124: , 1998

35. Systemic Antifungals Alternate effect of antifungals Kanda et.al
CD3/CD28 cells from atopic derm and controls
In vitro T-cell helper-1 (TH1) and T-cell helper-2 (TH2) cytokines studied in response to antimycotics
Results
Azole derivatives suppressed expression of IL-4 and IL-5 by reducing 3,5 cAMP signal
It is reported that anti-mycotic agents are effective for the treatment of patients with atopic dermatitis. We studied the in vitro effects of anti-mycotics on T-cell helper-1 (TH1) and T-cell helper-2 (TH2) cytokine production in anti-CD3 plus anti-CD28-stimulated T cells from atopic dermatitis patients and normal donors. The amounts of IL-4 and IL-5 secreted by anti-CD3/CD28-stimulated T cells were higher in atopic dermatitis patients than in normal donors. Azole derivatives, ketoconazole, itraconazole, miconazole, and nonazole terbinafine hydrochloride, and tolnaftate reduced IL-4 and IL-5 secretion without altering that of interferon-gamma and IL-2 in anti-CD3/CD28-stimulated T cells from both atopic dermatitis patients and normal donors. The azole derivatives were more inhibitory than nonazole anti-mycotics. These anti-mycotics reduced the anti-CD3/CD28-induced mRNA expression and promoter activities for IL-4 and IL-5. The 3',5'-cyclic adenosine monophosphate analog dibutyryl 3',5'-cyclic adenosine monophosphate reversed the inhibitory effects of the anti-mycotics on IL-4 and IL-5 secretion, mRNA expression, and promoter activities. Anti-CD3/CD28 transiently (<5 min) increased intracellular 3',5'-cyclic adenosine monophosphate in T cells, and the increase was greater in atopic dermatitis patients than in normal donors. The increase of 3',5'-cyclic adenosine monophosphate by anti-CD3/CD28 correlated with IL-4 and IL-5 secretion by anti-CD3/CD28. The transient 3',5'-cyclic adenosine monophosphate increase was suppressed by anti-mycotics, and azole derivatives were more suppressive than nonazoles. Azole derivatives inhibited the activity of cyclic adenosine monophosphate-synthesizing adenylate cyclase whereas terbinafine hydrochloride and tolnaftate enhanced the activity of 3',5'-cyclic adenosine monophosphate-hydrolyzing cyclic nucleotide phosphodiesterase in atopic dermatitis and normal T cells. These results suggest that the anti-mycotics may suppress IL-4 and IL-5 production by reducing 3',5'-cyclic adenosine monophosphate signal, and stress their potential use for the suppression of T helper-2-mediated inflammatory processes.
Kanda N. Journal of Investigative Dermatology. 117(6): , 2001 Dec.

36. Topical Antifungals Test of fungal hypothesis Methods
Double blind placebo controlled
24 CRS subjects randomized
Ampho B irrigation - 10
Saline control - 14
Results
CT scores
SNOT – 20 – no sig change
Endoscopy (7/10, 5/14)
IL-5 – no sig change
Eosinophils – no sig change
Alternaria – no change
Conclusion – Ampho B works
Background: Chronic rhinosinusitis (CRS) is one of the most
common chronic diseases. Its etiology is unknown, and there
is a paucity of effective medical treatments.
Objective: We tested the hypothesis that intranasal antifungal
treatment improves the objective computed tomography (CT)
findings (inflammatory mucosal thickening), nasal endoscopy
stages, and symptoms of CRS.
Methods: A randomized, placebo-controlled, double-blind,
single-center trial used amphotericin B to treat 30 randomly
selected patients with CRS. Patients were instructed to instill
20 mL amphotericin B (250 mg/mL) or placebo to each nostril
twice daily for 6 months. The primary outcome was
a quantitative reduction in inflammatory mucosal thickening
on CT scans of a standardized coronal cut. Secondary outcome
measures were endoscopic scores, patient symptom scores, and
levels of intranasal inflammatory mediators.
Results: Twenty-four patients completed the 6 months of
treatment. Patients receiving amphotericin B achieved
a relative reduction in the percentage of mucosal thickening
on CT scans (n = 10; 28.8%) compared with placebo (n = 14;
12.5%; P = .030). Likewise, the changes in the endoscopic
scores improved in the amphotericin B group compared with
placebo (P = .038). Between-group comparisons of the changes
in the intranasal mucus levels of eosinophil-derived neurotoxin
showed a reduction in the amphotericin B group and an
increase in the placebo group (P = .046); levels of IL-5
showed similar tendencies (P = .082).
Ponikau, et al. JACI 2005;115:

37. Stratification Issues
Alternaria
No change over 6 months
Does this support hypothesis?
Stratification Issues
Demographics
Inflammatory Mediators
EDN
IL-5
Ponikau, et al. JACI 2005;115:125-31

38. Topical Antifungals Test of fungal hypothesis Methods
Double blind placebo controlled
74 CRS subjects randomized
Ampho B spray
Saline control
Results
60 completed the study
Conclusion – no effect
Controversy in delivery
Background: Recently, fungal elements were suspected to be
the causative agent of chronic rhinosinusitis, and benefits of
topical amphotericin B therapy have been reported.
Objective: The effects of amphotericin B versus control nasal
spray on chronic rhinosinusitis were compared in a doubleblind,
randomized clinical trial.
Methods: Patients with chronic rhinosinusitis were
administered 200 mL per nostril amphotericin B (3 mg/mL) or
saline nasal spray 4 times daily over a period of 8 weeks. The
response rate, defined as a 50% reduction of pretreatment
computed tomography score, was the primary outcome
variable. Additional outcome variables included a symptom
score, a quality of life score, and an endoscopy score. Before
and after treatment, nasal lavages were pretreated with
dithiothreitol and examined for fungal elements by PCR and
standard culture techniques.
Results: Seventy-eight patients were included, and 60 patients
finished the study per protocol. In the control group, no positive
response (0 of 32) was observed, and 2 of 28 patients responded
in the amphotericin B group (P > .2). The symptom scores were
distinctly worse after amphotericin B therapy (P < .005). The
other parameters investigated did not differ remarkably
between the treatment groups.
Conclusion: Nasal amphotericin B spray in the described
dosing and time schedule is ineffective and deteriorates patient
symptoms. (J Allergy Clin Immunol 2004;113: )
Weshta, et al. JACI 2004;113:

39. Recidivism after treatment
Bent - Near 100% recurrence in absence of medical treatment
Kupferberg - 19/24 patients recurred after d/c of steroids
Schubert - 67pts
Steroids for >2 mo. - 35% 1yr
Steroids for <2 mo. - 55% 1yr
Marple, Mabry - 42pts
Immunotherapy - 10% mo.
Marple, Newcomer - 17pts followed yrs.
1/17 with recurrence of AFS
No decrease in fungal IgE
No difference in treatment arms
Allergy Asthma Proc 1996;17:259-68,
Oto-HNS 1997;117:35-41,
J Allergy Clin Immunol1998;102: ,
Am J Rhinology 2000;14:223-26
Oto-HNS: (5) 361-6

40. Conclusion AFS remains intriguing Elimination of Fungal Antigen
Control of Recurrence
Immunomodulation Antifungal Rx
IT Steroids Topical Systemic
AFS remains intriguing
Subset of CRS
Surgery
Crucial part of treatment
Medical follow-up appears crucial to long-term success
Need for evidence-based studies

41. Experience of Others Braun – 92 patients with CRS
Replicated findings of 1999 Ponikau paper
Richetti – 74 patients with nasal polyps
Ampho B irrigation for 4 weeks
47% experienced complete resolution of polyps
Proposed mechanism of effect
Ampho B antifungal effect, OR
Ampho B possesses well-known anti-inflammatory effect!!!
These findings are not unique to the Mayo.
Braun. Laryngoscope 2003;113:
Richetti. J of Laryngol & Otol 2002;116:

42. Fungal Specific Humoral Response
Classification of Diseases
EMCRS Controls
CRS ARFA HV
n= n= n=15
AFS AFS-Like NAFES NANFES
n= n= n= n=5
Pant H, Laryngoscope 2005;115:

43. Chronic rhinosinusitis
Clinical classification of CRS
Anatomic abnormalities,
humoral immune deficiency,
abnormal mucociliary function
Chronic rhinosinusitis
(CRS)
Allergic rhinitis
Bacterial
Infection
CRS without NP
CRS with NP
With eosinophilic
Inflammatory
features
With other
inflammatory
features
With other
Inflammatory
features
With eosinophilic
Inflammatory
features
Without
fungal
hyphae
Eosinophilic
mucin with fungal
hyphae (and positive
fungal skin tests)
“classic AFS”
Vaso-
motor
rhinitis
Non-
allergic
rhinitis
GERD
Sarcoid-
osis
Non-
allergic
rhinitis
Meltzer, Hamilos, Hadley, Lanza, Marple, et. al. Rhinosinusitis: Establishing Definitions for Clinical Research and Patient Care. JACI 2004;114:
ASA
tolerant
ASA
sensitive
ASA
tolerant
ASA
sensitive

44. Treatment of AFS: a comparison trial of postoperative IT with specific fungal antigens1
Conclusion -
“We report our experience dating to Aug in the management of AFS. Based upon endoscopic staging, quality of life assessment, and comparison with the usual course of AFS, immunotherapy with relevant fungal antigens is not harmful, and appears to be beneficial.”
1Folker, Marple, Mabry, Mabry, Laryngoscope 108: , 1998

45. Controversies Surrounding Fungal Rhinosinusitis
Does the data presented prove fungus as the sole cause of CRS?
Does the existence of EFRS negate that of AFRS (or all other causes of CRS)?
Does it diminish the association with sIgE?
Two amongst the controversies.

46. Corticosteroids: How to use (Marple, Mabry, Am J Rhinol 12:263-68,1998)
Preop
Start mg/kg/day to start 1 week prior to surgery
Postop
Resume mg/kg/day
Taper over 4 weeks
Continue low dose, alternate day therapy, or
Start immunotherapy, or
Start antifungal therapy

47. Antifungal antimicrobials
Used initially to arrest the potential progression to invasive fungal disease
Next used in an attempt to control recidivism of disease
Amphoterocin B
Toxicity limits use
Ketoconazole, itraconazole, fluconazole
Poor in vitro activity to dematiaceous fungi1
1Manning, et al, Laryngoscope 108; ,1998

48. Fungal Specific Humoral Response
Conclusions of study
Fungal spIgE fails to differentiate AFS
Fails to support central pathogenic role of spIgE
spIgE may simply be involved in exacerbation of underlying inflammation in some forms of EMCSF
Fungal spIgG3
Served as marker of EM production
Separated EMCRS from CRS
Pant H, Laryngoscope 2005;115: