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Management of allergic fungal sinusitis with postoperative oral and nasal steroids: A controlled study

MANAJEMEN SINUSITIS ALERGI JAMUR DENGAN PASCA OPERASI MULUT DAN STEROID HIDUNG : DENGAN PENELITIAN STUDI KONTROL
March 31, 2009 by Mubasher Ikram, FCPS, Akbar Abbas, FCPS, Anwar Suhail, FRCS, Maisam Abbas Onali, MBBS,

Shabbir Akhtar, FCPS, and Moghira Iqbal, FCPS

Abstract
In patients with allergic fungal sinusitis, the mainstay of treatment remains surgical removal of allergic mucin and fungal debris. But as a single modality, surgery is associated with high rates of recurrence, so a number of adjunctive medical modalities have been tried, including postoperative corticosteroid therapy. We conducted a study of 63 patients with allergic fungal sinusitis who underwent endoscopic sinus surgery with or without postoperative steroid therapy. A group of 30 patients who had been treated prior to January 2000 had undergone surgery only; their cases were reviewed retrospectively, and they served as historical controls. Another 33 patients who were treated after June 2000 underwent surgery plus oral and nasal steroid therapy. All patients were followed for a minimum of 2 years. Recurrences were seen in 50.0% (15/30) of the no-steroid group and 15.2% (5/33) of the steroid group-a statistically significant difference (p = 0.008). The results of our study strongly support the use of steroids to control allergic fungal sinusitis and prevent its recurrence, and we recommend further study to identify the optimal dosage and duration of therapy.

Ringkasan Pasien dengan sinusitis alergi jamur, pengobatan yang paling utama tetap operasi pengakatan alergi musin dan debris jamur. Tapi sebagai modalitas tunggal, operasi dihubungkan dengan tingkat kekambuhan yang tinggi, sehingga sejumlah modalitas medis ajuvan telah dicoba, termasuk terapi steroid pasca operasi. Kami melakukan studi terhadap 63 pasien dengan sinusitis alergi jamur yang menjalani operasi endoskopi sinus dengan atau tanpa terapi steroid pasca operasi. 30 pasien yang telah diobati sebelum Januari 2000 telah menjalani operasi saja; kasus mereka diperiksa secara retrospektif, dan mereka menyajikan sejarah kontrol. Berbeda dengan 33 pasien yang telah dirawat setelah Juni 2000 menjalani operasi ditambah terapi steroid oral dan hidung. Semua pasien diikuti minimal selama 2 tahun. Kejadian kekambuhan 50,0% (15/30) dari kelompok tidak diberikan steroid dan 15,2% (5/33) dari kelompok yang dengan steroid perbedaan yang signifikan (p = 0,008). Hasil penelitian kami sangat mendukung penggunaan steroid untuk menggendalikan sinusitis alergi jamur dan mencegah kekambuhan, dan kami sarankan dilakukan studi lanjutan untuk mengetahui konsentrasi dan dosis optimal dan waktu pengobatannya.

Introduction
Allergic fungal sinusitis was first described in the early 1980s by Millar et al 1 in the United Kingdom and by Katzenstein et al2 in the United States. The organisms responsible for most cases of this disease areAspergillus spp and members of the family of dematiaceous fungi.3,4 Typically, patients are young and immunocompetent, and they present with a history of atopic disease.

Latar Belakang Sinusitis alergi jamur pertama kali dijelaskan pada awal 1980an oleh Miller dkk di Inggris dan oleh Katzenstein dkk di Amerika Serikat. Organisme yang bertanggung jawab untuk sebagain besar kasus penyakit ini adalah Aspergillus spp dan familinya dematiaceous fungi. Biasanya, pasien yang masih muda dan imunokompeten, dan mereka yang datang dengan riwayat penyakit atopik.
The onset of allergic fungal sinusitis occurs with the inhalation of fungal spores to which the patient is allergic. In response, the sinonasal mucosa produces a copious amount of secretions (mucin), but the process of mucociliary clearance fails to remove the spore. The fungal spore then germinates in the mucin and continues to provide an antigenic stimulus. Polyps and hyperplastic mucosa form as a result of the inflammatory stimulus.

Terjadinya sinusitis alergi jamur terjadi melalui inhalasi spora jamur pada pasien yang alergi. Sebagai efeknya, sinonasl mukosa menghasilkan sekret yang berlebih (mucin), tapi mekanisme mucociliary clearance gagal membuang spora. Pada spora jamu kemudian bercabang di kelenjar dan terus memberikan stimulus antigenik. Polip dan membentuk hiperplastik mukosa sebagai akibat dari stimulus inflamasi.
The diagnostic criteria for allergic fungal sinusitis include the presence of nasal polyposis, atopy to fungi, characteristic findings on computed tomography (CT) and magnetic resonance imaging, and a characteristic histopathologic picture in which fungal hyphae are found in eosinophilic mucin without evidence of tissue invasion.5,6 Kriteria diagnostik untuk sinusitis jamur alergi termasuk kehadiran hidung poliposis, atopi terhadap jamur, temuan karakteristik pada computed tomography (CT) dan magnetic resonance imaging, dan gambar histopatologi karakteristik dimana hifa jamur yang ditemukan di eosinofilik musin tanpa bukti invasi jaringan Kriteria diagnostik untuk sinusitis alergi jamur termasuk terjadinya polip hidung, atopi terhadap jamur, karakteristik dari computed tomography (CT) dan magnetic resonance imaging, dan gambaran karakteristik histopatologi dimana hifa jamur ditemukan di eosinofilik musin tanpa ada invasi ke jaringan. The management of allergic fungal sinusitis is difficult, and treatment failure is common. In fact, recurrence rates as high as 100% have been reported following surgical management. 5,7 In an effort to lower the risk of recurrence, the use of postoperative medical treatment with corticosteroids has been tried in various centers worldwide, based on experience with the treatment of allergic bronchopulmonary asperigillosis. 8 Pengelolaan sinusitis jamur alergi sulit, dan kegagalan pengobatan adalah umum. Bahkan, tingkat kekambuhan setinggi 100% telah dilaporkan mengikuti bedah management.5, 7 Dalam upaya untuk menurunkan risiko kekambuhan, penggunaan perawatan medis pasca operasi dengan kortikosteroid telah dicoba di berbagai pusat di seluruh dunia, berdasarkan pengalaman dengan pengobatan alergi bronkopulmonalis asperigillosis Management sinusitis alergi jamur sangat sulit, dan kegagalan dalam pengobatan sudaa sering. Bahkan, tingkat kekambuhan setinggi 100% telah dilaporkan diikuti dengan management bedah. Dalam upaya untuk menurunkan risiko kekambuhan, penggunaan perawatan medis pasca operasi dengan kortikosteroid telah dicoba diberbagai pusat diseluruh dunia, berdasarkan dengan pengalaman pengobatan alergi bronkopulmonalis asperigillosis We report our experience in managing patients with allergic fungal sinusitis who had endoscopic sinus surgery with and without adjunctive postoperative steroids.

Kami melaporkan pengalaman kami dalam mengelola pasien dengan sinusitis operasi sinus endoskopi dengan dan tanpa steroid pasca operasi ajuvan.

alergi jamur yang menjalani

Patients and methods Pasien dan metode


The purpose of this study was to determine if the addition of postoperative steroid therapy has any effect on preventing recurrences in patients who undergo endoscopic sinus surgery for the treatment of allergic fungal sinusitis. The study was conducted at the Department of Otolaryngology-Head and Neck Surgery at the Aga Khan University Hospital in Karachi, Pakistan. The study population was drawn from patients who had been diagnosed with allergic fungal sinusitis on the basis of characteristic clinical findings and confirmed by intraoperative findings (mucin and fungal debris) and histopathologic analysis. Exclusion criteria included invasive infection that extended beyond the nose and paranasal sinuses, immunocompromise, failure to participate in regular follow-up, and revision surgery. Tujuan dari penelitian ini adalah untuk menentukan apakah penambahan terapi steroid memiliki efek pasca operasi untuk mencegah kekambuh pada pasien yang menjalani operasi sinus endoskopi untuk terapi sinusitis alergi jamur. Penelitian dilakukan di Departemen THT-Bedah Kepala dan Leher di Aga Khan University Hospital di Karachi, Pakistan. Populasi penelitian diambil dari pasien yang telah didiagnosis dengan sinusitis alergi jamur berdasarkan temuan karakteristik klinis dan dikonfirmasi oleh temuan intraoperatif (musin dan debris jamur) dan analisis histopatologi. Kriteria eksklusi meliputi infeksi invasif yang melebihi hidung dan sinus paranasal, immunocompromise, kegagalan untuk berpartisipasi dalam follow-up biasa, dan revisi operasi. This study was conducted in two parts-a prospective phase and a retrospective review. In the prospective phase, we studied 33 patients-21 men and 12 women (mean age: 31 yr)-whose sinusitis was treated with surgery plus steroid therapy (steroid group). For comparison purposes, we reviewed the records of 30 historical controls-16 men and 14 women (mean age: 29 yr)-who met the same inclusion and exclusion criteria and whose sinusitis had been treated with surgery only (no-steroid group). All patients in the no-steroid group had been treated prior to 2000, when it was not the policy of our institution to administer adjunctive postoperative steroid therapy. All patients in the steroid group were treated after June 2000. All 63 patients in this study were operated on in our department by a single surgeon (M. Ikram). Penelitian ini dilakukan dalam dua bagian-fase prospektif dan retrospektif. Dalam fase prospective, kita mempelajari 33 pasien-21 pria dan 12 wanita (usia rata-rata: 31 tahun) dengan sinusitis yang diobati dengan pembedahan ditambah terapi steroid (kelompok steroid). Untuk tujuan perbandingan, kami meninjau catatan dari 30 riwayat kontrol-16 pria dan 14 wanita (usia rata-rata: 29 tahun)-yang memenuhi inklusi dan kriteria eksklusi yang sama dan dengan sinusitis yang telah diobati dengan pembedahan saja (kelompok no-steroid). Semua pasien dalam kelompok no-steroid telah diobati sebelum tahun 2000, ketika itu bukan kebijakan dari lembaga kami untuk mengelola terapi ajuvan steroid pasca operasi. Semua pasien dalam kelompok steroid dirawat setelah Juni 2000. Semua 63 pasien dalam penelitian ini dioperasi di departemen kami oleh seorang ahli bedah sendiri(M. Ikram). In the steroid group, patients were prescribed postoperative oral prednisone (0.5 mg/kg) for 1 month, followed by topical beclamethasone (2 sprays in each side twice daily) for 5 months. If the appearance of the nasal mucosa was greater than stage 0 as described by Kupferberg et al 5 during nasal steroid therapy, a short course of oral steroids at 0.5 mg/kg/day for 1 to 2 weeks was given to restore the mucosa to stage 0. Pada kelompok steroid, pasien diberi resep pascaoperasi prednison oral (0,5 mg / kg) selama 1 bulan, diikuti oleh beclamethasone topikal (2 semprotan di setiap sisi dua kali sehari) selama 5 bulan. Jika penampilan

mukosa hidung lebih besar dari stadium 0 seperti yang dijelaskan oleh Kupferberg dkk selama terapi steroid hidung, dalam waktu singkat diberikan steroid oral pada 0,5 mg / kg / hari selama 1 sampai 2 minggu diberikan untuk mengembalikan mukosa untuk stadium 0 All patients were followed for a minimum of 2 years. Patients were seen for follow-up once a month for 6 months, then once every 3 months for at least 18 months. At the monthly follow-ups, all patients underwent nasal endoscopy and measurement of their IgE level. All patients were actively encouraged to perform daily nasal lavage with normal saline, which we believe helps clear crust and debris from the nose. All recurrences were treated with revision surgery. Semua pasien diikuti selama minimal 2 tahun. Pasien difollow up sebulan sekali selama 6 bulan, kemudian setiap 3 bulan sekali selama setidaknya 18 bulan. Pada follow up beberapa bulan, semua pasien dilakukan endoskopi hidung dan pengukuran tingkat IgE mereka. Semua pasien didorong untuk aktif melakukan lavage nasal sehari-hari dengan saline normal, yang kami percaya membantu membersihkan kotoran dan debris dari hidung. Semua kambuh diobati dengan operasi berulang. Our data were statistically analyzed with the aid of the Statistical Package for the Social Sciences software (version 13; SPSS; Chicago), and recurrence data were subjected to Kaplan-Meier analysis. Data kami dianalisis secara statistik dengan bantuan Paket Statistik untuk Ilmu Sosial perangkat lunak (versi 13, SPSS, Chicago), dan data kekambuhan menjadi sasaran analisis Kaplan-Meier.

Results resume
At presentation, most patients had bilateral disease, nasal polyps, nasal obstruction, and headache (table 1). Pada presentasi, kebanyakan pasien memiliki penyakit bilateral, polip hidung, sumbatan hidung, dan sakit kepala (tabel 1).

Table 1. Presenting symptoms in the two groups


No steroid n (%) Unilateral/bilateral disease Nasal polyps Nasal obstruction Headache Anosmia 11/19(36.7/63.3) 30 (100) 30 (100) 27 (90.0) 13 (43.3) Steroid n (%) 14/19(42.4/57.6) 33 (100) 33 (100) 25 (75.8) 18 (54.5)

Allergic fungal sinusitis recurred in 15 of the 30 no-steroid patients (50.0%), compared with only 5 of the 33 steroid patients (15.2%). The difference was statistically significant ( p = 0.008). Sinusitis jamur alergi kambuh pada 15 pasien tanpa steroid 30 (50,0%), dibandingkan dengan hanya 5 dari 33 pasien steroid (15,2%). Perbedaan itu bermakna secara statistik (p = 0,008). According to the Kaplan-Meier analysis, the probability of treatment response was 0.8 in the no-steroid group (table 2) and 0.9 in the steroid group (table 3). The cumulative probability of remaining disease-free was 0.4656 in the no-steroid group and 0.8156 in the steroid group (figure, table 2, and table 3). Menurut analisis Kaplan-Meier, kemungkinan respon pengobatan adalah 0,8 pada kelompok no-steroid (tabel 2) dan 0,9 pada kelompok steroid (tabel 3). Kumulatif probabilitas tetap bebas penyakit adalah 0,4656 dalam kelompok no-steroid dan 0,8156 pada kelompok steroid (gambar, tabel 2, dan tabel 3).

Table 2. Probability of treatment response and cumulative probability of remaining disease-free in the no-steroid group (Kaplan-Meier analysis) Tabel 2. Probabilitas respon pengobatan dan kemungkinan kumulatif yang tersisa bebas penyakit dalam kelompok no-steroid (Kaplan-Meier analisis)
Study day 0 150 180 270 360 450 540 630 720 Patients w/o recurrence n Probability (%) response 30 (100) 30 (100) 29 (96.7) 28 (93.3) 27 (90.0) 26 (86.7) 24 (80.0) 23 (76.7) 22 (73.3) 1.0 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 of Cumulative probability 1.0000 0.9666 0.9326 0.8992 0.8658 0.7991 0.7657 0.7323 0.6989

810 900 990 1,080 15

21 (70.0) 19 (63.3) 17 (56.7) (50.0)

0.9 0.8 0.9 0.8

0.6322 0.5656 0.5322 0.4656

Table 3. Probability of treatment response and cumulative probability of remaining disease-free in the steroid group (Kaplan-Meier analysis) Tabel 2. Probabilitas respon pengobatan dan kemungkinan kumulatif yang tersisa bebas penyakit dalam kelompok steroid (Kaplan-Meier analisis)
Study day 0 450 630 810 900 990 Patients w/o recurrence n Probability (%) response 33 (100) 33 (100) 32 (97.0) 30 (90.9) 29 (87.9) 28 (87.9) 1.0 0.9 0.9 0.9 0.9 0.9 of Cumulative probability 1.0000 0.9696 0.9090 0.8786 0.8483 0.8156

Figure. Kaplan-Meier curve shows the cumulative probability of remaining disease-free in the two groups at study's end-0.8156 in the sterooid group and 0.4656 in the no-steroid group Gambar. Kurva Kaplan-Meier menunjukkan probabilitas kumulatif yang tersisa bebas penyakit pada kedua kelompok pada penelitian akhir0,8156 pada kelompok sterooid dan 0,4656 dalam kelompok no-steroid

No patient in the steroid group reported any serious side effects of steroid therapy. Six patients (18.2%) experienced skin spots during the final week of their oral steroid regimen, but these lesions disappeared upon the conclusion of oral therapy. Tidak ada pasien dalam kelompok steroid dilaporkan adanya efek samping yang serius dari terapi steroid. Enam pasien (18,2%) mengalami bintik-bintik kulit selama minggu terakhir dengan rejimen steroid oral, tetapi lesi ini menghilang pada akhir terapi oral

Discussion
A number of contributing factors are associated with allergic fungal sinusitis. For example, atopy, continuous exposure to antigens, and inflammation all play key roles in the disease and its recurrence. 9 Sejumlah faktor yang berhubungan dengan sinusitis alergi jamur . contohnya, atopi, paparan terus-menerus terhadap antigen, dan semua peradangan memainkan peran penting dalam penyakit dan tejaddinya kekambuhan. Historically, all forms of fungal sinusitis were treated with a combination of extensive surgical debridement and medical treatment.10 However, in most early reports, allergic fungal sinusitis was not adequately distinguished from other forms of fungal sinusitis, and this made it difficult to compare different treatments. 11 Secara historis, semua bentuk sinusitis jamur diobati dengan kombinasi extensive operasi debridement dan terapi pengobatan. Namun, dalam laporan yang paling awal, sinusitis alergi jamur tidak cukup dibedakan dari bentuk lain dari sinusitis jamur, dan ini sulit membandingkan berbeda terapi.

Ever since allergic fungal sinusitis was first described, 1,2 the primary mode of treatment has been surgical resection of allergic mucin and obstructing hypertrophic mucosal disease. More recently, conservative surgical procedures such as endoscopic debridement have been advocated. 12 Today, in addition to the surgical removal of allergic mucin and fungal debris, treatment includes the creation of patent sinus ostia that are large enough for adequate aeration and drainage of sinuses. But as mentioned, endoscopic sinus surgery is associated with high rates of recurrence.5,7 In an effort to reduce these recurrence rates, researchers have tried various medical therapies as adjunctive treatment, including antifungal agents, immunotherapy, and steroids. Sejak sinusitis alergi jamur pertama kali dijelaskan, 1,2 model utama dari pengobatan adalah bedah reseksi kelenjar alergi dan penyakit obstruksi hipertrofi mukosa. Baru-baru ini, prosedur bedah konservatif seperti debridement endoskopi telah menjadi hal baru. Hari ini, selain operasi pengangkatan kelenjar alergi dan debris jamur, pengobatan meliputi pembentukan permanen sinus ostia yang cukup besar untuk irigsi dan drainase yang cukup untuk sinus. Tapi seperti yang disebutkan, bedah sinus endoskopi berhubungan dengan tingginya tingkat kekambuhan. Dalam upaya untuk mengurangi tingkat kekambuhan ini, peneliti telah mencoba berbagai terapi medis sebagai pengobatan tambahan, termasuk agen antijamur, imunoterapi, dan steroid. Antifungal agents. The authors of some early reports recommended the use of antifungal drugs, 13,14 but no prospective, controlled studies have been conducted to support their use. In fact, in noninvasive fungal disease, the risks associated with these medications may outweigh their benefits. 15 Ricch-etti et al reported that the use of a topical antifungal (amphotericin B nasal lavage) prevented recurrences in nasal polyposis, but the patients in that study had not been diagnosed with classic allergic fungal sinusitis and the study had no control group.16 Therefore, further investigation is needed to confirm their findings. Agen antijamur. Para penulis dari beberapa laporan awal merekomendasikan penggunaan obat antijamur, 13,14 tetapi tidak ada prospektif, studi terkontrol telah dilakukan untuk mendukung penggunaannya. Bahkan, dalam penyakit jamur invasif, risiko yang terkait dengan obat-obat ini mungkin lebih besar daripada keuntungannya.15 Ricch-Etti dkk melaporkan bahwa penggunaan antijamur topikal (amfoterisin B hidung lavage) mencegah kekambuhan polip dihidung, tetapi pasien dalam penelitian belum didiagnosis dengan klasik sinusitis alergi jamur dan penelitian tidak memiliki kelompok kontrolnya. Oleh karena itu, penyelidikan lebih lanjut diperlukan untuk mengkonfirmasi temuan mereka. Immunotherapy. The similarity between allergic fungal sinusitis and allergic bronchopulmonary aspergillosis led to an empiric and theoretical intimation that immunotherapy may be beneficial as a component of treatment of the former.8 Mabry et al conducted rigorous investigations and found that patients who had undergone immunotherapy in addition to surgery and postoperative steroid therapy experienced less crusting and less recurrence of nasal polyps.17,18 In a subsequent study of outcomes in 8 patients following the discontinuation of immunotherapy, Mabry et al reported no recurrences during 7 to 17 months of follow-up.19 In contrast, Ferguson found that patients on immunotherapy either did not improve or actually worsened.20 As a result, more study is needed before immunotherapy can be widely accepted as the primary mode of treatment for allergic fungal sinusitis. Imunoterapi. Kesamaan antara sinusitis alergi jamur al dan bronchopulmonary aspergillosis alergi menyebabkan empiris dan teoritis tanda bahwa imunoterapi dapat bermanfaat sebagai komponen pengobatan. Mabry dkk melakukan penyelidikan ketat dan menemukan bahwa pasien yang telah menjalani imunoterapi selain operasi dan terapi steroid pasca operasi mengalami menurunnya pembentukan krusta dan menurunya kekambuhnya polip hidung. Pada penelitian selanjutnya hasil di 8 pasien setelah penghentian imunoterapi, Mabry dkk melaporkan tidak terjadi kekambuh selama 7 sampai 17 bulan dari masa follow up. Sebaliknya, Ferguson

menemukan bahwa pada pasien imunoterapi lebih baik tidak diterima atau benar-benar berpengaruh. Akibatnya, studi lebih lanjut diperlukan sebelum imunoterapi dapat diterima secara luas sebagai model utama dari pengobatan untuk sinusitis alergi jamur. Steroids. The similarity between allergic fungal sinusitis and allergic bronchopulmonary aspergillosis also prompted the use of steroids, and many authors advocate their use. In one early report, Waxman et al outlined this relationship and suggested the use of systemic steroids postoperatively. 21 Since then, both systemic and topical steroids have been recommended, although the optimal dosage and the duration of therapy remain unclear.5,10,22-25 Steroid. Kesamaan antara sinusitis alergi jamur al dan bronchopulmonary aspergillosis alergi juga mendorong penggunaan steroid, dan banyak penulis menganjurkan penggunaannya. Dalam satu laporan awal, Waxman dkk menguraikan hubungan ini dan menyarankan penggunaan steroid sistemik setelah pengobatan. Sejak itu, keduanya steroid sistemik dan topikal telah direkomendasikan, meskipun dosis optimal dan durasi terapi tetap tidak jelas In a study of 26 patients with allergic fungal sinusitis, Kupferberg et al found that steroids were associated with greater improvements.5 Likewise, Schubert and Goetz retrospectively analyzed outcomes among 67 patients treated and followed over a period of 8 years. 11 All patients had been treated similarly with respect to sinus surgery, immunotherapy, anti-inflammatory nasal sprays, and antihistamines. Roughly half of these patients were treated with postoperative oral steroids and the other half were not. The use of oral steroids was associated with greater clinical improvement and a significantly lower incidence of revision sinus surgery. Dalam sebuah penelitian terhadap 26 pasien dengan sinusitis alergi jamur alergi, Kupferberg dkk menemukan bahwa steroid dikaitkan dengan perbaikan. Demikian juga, Schubert dan Goetz menganalisis secara retrospektif hasil antara 67 pasien dirawat dan diikuti selama 8 tahun. Semua pasien telah diperlakukan sama sehubungan dengan operasi sinus, imunoterapi, semprotan hidung anti-inflamasi, dan antihistamin. Kira-kira setengah dari pasien ini diobati dengan steroid oral pasca operasi dan setengah lainnya tidak. Penggunaan steroid oral dikaitkan dengan perbaikan klinis yang lebih besar dan kejadian secara signifikan lebih rendah dari operasi perbaikan sinus. Kuhn and Javer have advocated a postoperative steroid protocol that begins with oral prednisone at 0.4 mg/kg/day for 4 days.22 The dosage is decreased by 0.1 mg/kg/day every 4 days until it is lowered to either 20 mg/day or 0.2 mg/kg/day, whichever is greater. That low dose is continued for 1 month, at which point the dosage is adjusted so that all patients are given 0.2 mg/kg/day. That dose is maintained while patients are followed monthly with nasal endoscopy and measurements of their IgE level. Later, the steroid dosage is again adjusted to maintain the patient's nasal membrane appearance at stage 0. For patients who maintain a stage 0 appearance for 4 months, the dosage of oral steroid is decreased to 0.1 mg/kg/day and a topical steroid is added. If stage 0 continues for 2 more months, then the oral steroid is tapered off completely and the topical steroid is continued for 1 year. Kuhn dan Javer telah menganjurkan sebuah protokol steroid pascaoperasi yang diawali dengan prednison oral pada 0,4 mg / kg / hari selama 4 hari. Dosis diturun 0,1 mg / kg / hari setiap 4 hari sampai ada perbaikan diturunkan 20 mg / hari atau 0,2 mg / kg / hari, mana yang lebih baik. Itu dosis rendah dilanjutkan selama 1 bulan, di mana titik dosis disesuaikan sehingga semua pasien diberikan 0,2 mg / kg / hari. Dosis yang dipertahankan sementara pasien diikuti tiapnbulan dengan pemeriksaan endoskopi hidung dan pengukuran tingkat IgE mereka. Kemudian, dosis steroid disesuaikan untuk menjaga permukaan membran hidung pasien pada tahap 0. Untuk pasien yang bertahan dalam kondisi stadium 0 selama 4 bulan, dosis steroid oral diturunkan menjadi 0,1 mg / kg / hari dan steroid topikal ditambahkan. Jika tahap 0 berlanjut selama 2 bulan lebih, maka

steroid oral diditurunkan secara perlahan hingga tidak digunakan lagi dan steroid topikal dilanjutkan selama 1 tahun. The results of our study strongly support the use of oral and nasal steroids to control allergic fungal sinusitis and to prevent its recurrence. We recommend further study to identify the optimal dosage and duration of therapy. Hasil penelitian kami sangat mendukung penggunaan steroid oral dan hidung untuk mengontrol sinusitis alergi jamur dan untuk mencegah kekambuhan. Kami merekomendasikan studi lebih lanjut untuk mengetahui konsentrasi dan dosis optimal dan durasi terapi.

Acknowledgment Pengakuan
We are grateful to Dr. Iqbal Azam of the Department of Community Health Sciences at Aga Khan University Hospital for the statistical analysis of data. Kami berterima kasih kepada Dr Iqbal Azam dari Departemen Ilmu Kesehatan Masyarakat di Aga Khan University Hospital untuk analisis statistik data. From the Department of Otolaryngology-Head and Neck Surgery, Aga Khan University Hospital, Karachi, Pakistan. Mubasher Ikram, FCPS, Department of Otolaryngology-Head and Neck Surgery, Aga Khan University Hospital, Stadium Rd., PO Box 3500, Karachi 74800, Pakistan. Phone: 92-21-486-4779 or -4770; fax 92-21-493-4294 or -2095; e-mail: mubasher.ikram@aku.edu

References
1. 2. 3. Millar JW, Johnston A, Lamb D. Allergic aspergillosis of the maxillary sinuses [abstract]. Thorax 1981; 36:710. Katzenstein AL, Sale SR, Greenberger PA. Allergic Aspergillus sinusitis: A newly recognized form of sinusitis. J Allergy Clin Immunol 1983; 72 (1): 89-93. Michael RC, Michael JS, Ashbee RH, Mathews MS. Mycological profile of fungal sinusitis: An audit of specimens over a 7-year period in a tertiary care hospital in Tamil Nadu. Indian J Pathol Microbiol 2008; 51 (4): 493-6. Manning SC, Holman M. Further evidence for allergic pathophysiology in allergic fungal sinusitis. Laryngoscope 1998; 108 (10): 1485-96. Kupferberg SB, Bent JP III, Kuhn FA. Prognosis for allergic fungal sinusitis. Otolaryngol Head Neck Surg 1997; 117 (1): 35-41. Cody DT II, Neel HB III, Ferreiro JA, Roberts GD. Allergic fungal sinusitis: The Mayo Clinic experience. Laryngoscope 1994; 104 (9): 1074-9. Kuhn FA, Javer AR. Allergic fungal sinusitis: A four-year follow-up. Am J Rhinol 2000; 14 (3): 149-56. Greenberger PA, Patterson R. Diagnosis and management of allergic bronchopulmonary aspergillosis. Ann Allergy 1986; 56 (6): 444-8.

4. 5. 6. 7. 8.

9. Bent JP III, Kuhn FA. Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg 1994; 111 (5): 580-8. 10. Stevens MH. Primary fungal infections of the paranasal sinuses. Am J Otolaryngol 1981; 2 (4): 348-57. 11. Schubert MS, Goetz DW. Evaluation and treatment of allergic fungal sinusitis. II. Treatment and follow-up. J Allergy Clin Immunol 1998; 102 (3): 395-402. 12. Singh N, Bhalodiya NH. Allergic fungal sinusitis (AFS)-earlier diagnosis and management. J Laryngol Otol 2005; 119 (11): 875-81.

13. Frenkel L, Kuhls TL, Nitta K, et al. Recurrent Bipolaris sinusitis following surgical and antifungal therapy. Pediatr Infect Dis J 1987; 6 (12): 1130-2. 14. Corey JP, Delsupehe KG, Ferguson BJ. Allergic fungal sinusitis: Allergic, infectious, or both? Otolaryngol Head Neck Surg 1995; 113 (1): 110-19. 15. Thrasher RD, Kingdom TT. Fungal infections of the head and neck: An update. Otolaryngol Clin North Am 2003; 36 (4): 577-94. 16. Ricchetti A, Landis BN, Maffioli A, et al. Effect of anti-fungal nasal lavage with amphotericin B on nasal polyposis. J Laryngol Otol 2002; 116 (4): 261-3. 17. Mabry RL, Manning SC, Mabry CS. Immunotherapy in the treatment of allergic fungal sinusitis. Otolaryngol Head Neck Surg 1997; 116 (1 ∥: 31-5. 18. Mabry RL, Marple BF, Folker RJ, Mabry CS. Immunotherapy for allergic fungal sinusitis: Three years' experience. Otolaryngol Head Neck Surg 1998; 119 (6): 648-51. 19. Mabry RL, Marple BF, Mabry CS. Outcomes after discontinuing immunotherapy for allergic fungal sinusitis. Otolaryngol Head Neck Surg 2000; 122 (1): 104-6. 20. Ferguson BJ. Immunotherapy and antifungal therapy in allergic fungal sinusitis. Presented at the annual meeting of the American Academy of Otolaryngic Allergy; Sept. 14, 1993; Minneapolis. 21. Waxman JE, Spector JG, Sale SR, Katzenstein AL. Allergic Aspergillus sinusitis: Concepts in diagnosis and treatment of a new clinical entity. Laryngoscope 1987; 97 (3 Pt 1): 261-6. 22. Kuhn FA, Javer AR. Allergic fungal rhinosinusitis: Perioperative management, prevention of recurrence, and role of steroids and antifungal agents. Otolaryngol Clin North Am 2000; 33 (2): 419-33. 23. Ferguson BJ. What role do systemic corticosteroids, immunotherapy, and antifungal drugs play in the therapy of allergic fungal rhinosinusitis? Arch Otolaryngol Head Neck Surg 1998; 124 (10): 1174-8. 24. Schubert MS. Medical treatment of allergic fungal sinusitis. Ann Allergy Asthma Immunol 2000; 85 (2): 90-7. 25. Schubert MS. Allergic fungal sinusitis. Otolaryngol Clin North Am 2004; 37 (2): 301-26. Ear Nose Throat J. 2009 April;88(4):E08