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An Attempt to Resolve the Diagnostic Dilemma

Karuppiah Saravanan, MS, DNB; Naresh K. Panda, MS, DNB, FRCS(Ed); Arunaloke Chakrabarti, MD, DNB; Ashim Das, MD, MRCP; Rajeev J. Bapuraj, MD

Arch Otolaryngol Head Neck Surg. 2006;132:173-178.

Objective  To resolve the diagnostic dilemma of allergic fungal rhinosinusitis (AFRS), an increasingly recognized type of chronic rhinosinusitis (CRS). In spite of extensive studies, controversy exists regarding the etiologic characteristics, pathogenesis, and diagnosis of this entity.

Design  Prospective, comparative study.

Setting  Department of Otolaryngology–Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Patients  Seventy consecutive patients with CRS, with or without polyps.

Methods  Patients were evaluated by detailed clinical examination, computed tomography (CT), skin test against aspergillin antigen (47 patients), and histopathologic and mycologic monitoring. Based on the presence or absence of allergic mucin (M) and mycelial element (F) in the sinus, the patients were divided into 4 groups: M+F+ (likely AFRS group), M+F– (likely eosinophilic mucin rhinosinusitis), M–F+ (likely sinus mycetoma), and M–F– (CRS from other causes). The different parameters were compared in these 4 groups.

Results  Thirty-six patients were categorized in the likely AFRS group, 12 with eosinophilic mucin rhinosinusitis, 4 with sinus mycetoma, and 18 with CRS from other causes. Despite considerable overlap among different groups, the following parameters were significantly more associated with AFRS group: type 1 hypersensitivity (P<.05), Charcot-Leyden crystals (P<.001), bony erosion (P<.001), and heterogeneous opacity with sinus expansion on CT scan (P<.05). The above results were further validated in those patients for whom all investigations were conducted (n = 47). The significance of these 4 parameters with regard to AFRS was reconfirmed in those 47 patients.

Conclusions  To diagnose AFRS, important findings should be considered in addition to the detection of fungal elements and allergic mucin: Charcot-Leyden crystals, type 1 hypersensitivity, bony erosion, and heterogeneous opacity with sinus expansion on CT. The last 3 of these parameters may predict AFRS preoperatively.

Author Affiliations: Departments of Otolaryngology–Head and Neck Surgery (Drs Saravanan and Panda), Medical Microbiology (Dr Chakrabarti), Histopathology (Dr Das), and Radiodiagnosis (Dr Bapuraj), Postgraduate Institute of Medical Education and Research, Chandigarh, India.

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