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Allergic fungal rhinosinusitis

Rodney J Schlosser, MD
Daniel L Hamilos, MD
Section Editor
Jonathan Corren, MD
Deputy Editor
Anna M Feldweg, MD


Allergic fungal rhinosinusitis (AFRS) is a distinct type of chronic rhinosinusitis (CRS), accounting for between 5 and 10 percent of all CRS cases. AFRS is believed to result from chronic, intense allergic inflammation directed against colonizing fungi. Patients with AFRS are immunocompetent and show evidence of allergy to one or more fungi. Definitive diagnosis is usually confirmed after sinus surgery. Successful treatment involves a combination of surgical and medical management.

The pathogenesis, clinical manifestations, diagnosis, differential diagnosis, and management of AFRS are reviewed here. More general topics about CRS are found separately. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Chronic rhinosinusitis: Management".)


Allergic fungal rhinosinusitis (AFRS) is defined as a specific subtype of chronic rhinosinusitis (CRS). All forms of CRS are defined as inflammatory conditions involving the paranasal sinuses and linings of the nasal passages that last 12 weeks or longer. The diagnosis of all forms of CRS requires objective evidence of mucosal inflammation. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis", section on 'Definition'.)

AFRS is a distinct subtype of CRS that arises as a result of a localized allergic reaction to noninvasive fungal growth in areas of compromised mucus drainage [1,2]. AFRS is defined as an intense, localized allergic/eosinophilic inflammatory sinus disease that results in the accumulation of eosinophilic (allergic) mucin (a thick, tenacious eosinophilic secretion), which contains fungal hyphae, intense eosinophilic inflammation, and characteristic radiographic findings. The diagnostic criteria for AFRS require:

The presence of chronic rhinosinusitis with nasal polyposis (CRS with NP), unless the patient has undergone surgery or aggressive medical therapy with systemic glucocorticoids to remove or shrink the polyps.


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Literature review current through: Sep 2016. | This topic last updated: Aug 30, 2016.
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  1. Bush RK, Portnoy JM, Saxon A, et al. The medical effects of mold exposure. J Allergy Clin Immunol 2006; 117:326.
  2. Luong A, Marple BF. Allergic fungal rhinosinusitis. Curr Allergy Asthma Rep 2004; 4:465.
  3. Schubert MS, Goetz DW. Evaluation and treatment of allergic fungal sinusitis. II. Treatment and follow-up. J Allergy Clin Immunol 1998; 102:395.
  4. Hamilos DL, Lund VJ. Etiology of chronic rhinosinusitis: the role of fungus. Ann Otol Rhinol Laryngol Suppl 2004; 193:27.
  5. Luong A, Davis LS, Marple BF. Peripheral blood mononuclear cells from allergic fungal rhinosinusitis adults express a Th2 cytokine response to fungal antigens. Am J Rhinol Allergy 2009; 23:281.
  6. Pant H, Kette FE, Smith WB, et al. Fungal-specific humoral response in eosinophilic mucus chronic rhinosinusitis. Laryngoscope 2005; 115:601.
  7. Manning SC, Schaefer SD, Close LG, Vuitch F. Culture-positive allergic fungal sinusitis. Arch Otolaryngol Head Neck Surg 1991; 117:174.
  8. Torres C, Ro JY, el-Naggar AK, et al. Allergic fungal sinusitis: a clinicopathologic study of 16 cases. Hum Pathol 1996; 27:793.
  9. Ponikau JU, Sherris DA, Kern EB, et al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc 1999; 74:877.
  10. Cleland EJ, Bassiouni A, Boase S, et al. The fungal microbiome in chronic rhinosinusitis: richness, diversity, postoperative changes and patient outcomes. Int Forum Allergy Rhinol 2014; 4:259.
  11. Safirstein BH. Allergic bronchopulmonary aspergillosis with obstruction of the upper respiratory tract. Chest 1976; 70:788.
  12. Al-Dousary SH. Allergic fungal sinusitis: radiological and microbiological features of 59 cases. Ann Saudi Med 2008; 28:17.
  13. Revankar SG, Sutton DA. Melanized fungi in human disease. Clin Microbiol Rev 2010; 23:884.
  14. Dematiaceous fungi. Mount Sinai Hospital. http://microbiology.mtsinai.on.ca/mig/defungi/index.shtml (Accessed on June 23, 2015).
  15. Kimura M, McGinnis MR. Fontana-Masson--stained tissue from culture-proven mycoses. Arch Pathol Lab Med 1998; 122:1107.
  16. Shin SH, Ponikau JU, Sherris DA, et al. Chronic rhinosinusitis: an enhanced immune response to ubiquitous airborne fungi. J Allergy Clin Immunol 2004; 114:1369.
  17. Braun H, Stammberger H, Buzina W, et al. [Incidence and detection of fungi and eosinophilic granulocytes in chronic rhinosinusitis]. Laryngorhinootologie 2003; 82:330.
  18. Braun H, Buzina W, Freudenschuss K, et al. 'Eosinophilic fungal rhinosinusitis': a common disorder in Europe? Laryngoscope 2003; 113:264.
  19. Orlandi RR, Marple BF. Fungus and chronic rhinosinusitis: weighing the evidence. Otolaryngol Head Neck Surg 2010; 143:611.
  20. Okano M, Fujiwara T, Haruna T, et al. Role of fungal antigens in eosinophilia-associated cellular responses in nasal polyps: a comparison with enterotoxin. Clin Exp Allergy 2011; 41:171.
  21. Orlandi RR, Marple BF, Georgelas A, et al. Immunologic response to fungus is not universally associated with rhinosinusitis. Otolaryngol Head Neck Surg 2009; 141:750.
  22. Clark DW, Wenaas A, Luong A, et al. Staphylococcus aureus prevalence in allergic fungal rhinosinusitis vs other subsets of chronic rhinosinusitis with nasal polyps. Int Forum Allergy Rhinol 2013; 3:89.
  23. Dutre T, Al Dousary S, Zhang N, Bachert C. Allergic fungal rhinosinusitis-more than a fungal disease? J Allergy Clin Immunol 2013; 132:487.
  24. Ferguson BJ, Barnes L, Bernstein JM, et al. Geographic variation in allergic fungal rhinosinusitis. Otolaryngol Clin North Am 2000; 33:441.
  25. Wise SK, Ghegan MD, Gorham E, Schlosser RJ. Socioeconomic factors in the diagnosis of allergic fungal rhinosinusitis. Otolaryngol Head Neck Surg 2008; 138:38.
  26. Lu-Myers Y, Deal AM, Miller JD, et al. Comparison of Socioeconomic and Demographic Factors in Patients with Chronic Rhinosinusitis and Allergic Fungal Rhinosinusitis. Otolaryngol Head Neck Surg 2015; 153:137.
  27. Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol 2004; 114:155.
  28. Muntz HR. Allergic fungal sinusitis in children. Otolaryngol Clin North Am 1996; 29:185.
  29. Mafee MF. Imaging of paranasal sinuses and rhinosinusitis. Clin Allergy Immunol 2007; 20:185.
  30. Manning SC, Mabry RL, Schaefer SD, Close LG. Evidence of IgE-mediated hypersensitivity in allergic fungal sinusitis. Laryngoscope 1993; 103:717.
  31. Manning SC, Vuitch F, Weinberg AG, Brown OE. Allergic aspergillosis: a newly recognized form of sinusitis in the pediatric population. Laryngoscope 1989; 99:681.
  32. Marple BF, Gibbs SR, Newcomer MT, Mabry RL. Allergic fungal sinusitis-induced visual loss. Am J Rhinol 1999; 13:191.
  33. Soler ZM, Hyer JM, Ramakrishnan V, et al. Identification of chronic rhinosinusitis phenotypes using cluster analysis. Int Forum Allergy Rhinol 2015; 5:399.
  34. Smith TL, Mendolia-Loffredo S, Loehrl TA, et al. Predictive factors and outcomes in endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope 2005; 115:2199.
  35. Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995; 113:104.
  36. Hutcheson PS, Schubert MS, Slavin RG. Distinctions between allergic fungal rhinosinusitis and chronic rhinosinusitis. Am J Rhinol Allergy 2010; 24:405.
  37. Bent JP 3rd, Kuhn FA. Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg 1994; 111:580.
  38. Mukherji SK, Figueroa RE, Ginsberg LE, et al. Allergic fungal sinusitis: CT findings. Radiology 1998; 207:417.
  39. Nussenbaum B, Marple BF, Schwade ND. Characteristics of bony erosion in allergic fungal rhinosinusitis. Otolaryngol Head Neck Surg 2001; 124:150.
  40. Michaels L, Lloyd G, Phelps P. Origin and spread of allergic fungal disease of the nose and paranasal sinuses. Clin Otolaryngol Allied Sci 2000; 25:518.
  41. Bozeman S, deShazo R, Stringer S, Wright L. Complications of allergic fungal sinusitis. Am J Med 2011; 124:359.
  42. Ghegan MD, Lee FS, Schlosser RJ. Incidence of skull base and orbital erosion in allergic fungal rhinosinusitis (AFRS) and non-AFRS. Otolaryngol Head Neck Surg 2006; 134:592.
  43. McClay JE, Marple B, Kapadia L, et al. Clinical presentation of allergic fungal sinusitis in children. Laryngoscope 2002; 112:565.
  44. Marfani MS, Jawaid MA, Shaikh SM, Thaheem K. Allergic fungal rhinosinusitis with skull base and orbital erosion. J Laryngol Otol 2010; 124:161.
  45. Ghegan MD, Wise SK, Gorham E, Schlosser RJ. Socioeconomic factors in allergic fungal rhinosinusitis with bone erosion. Am J Rhinol 2007; 21:560.
  46. Zinreich SJ, Kennedy DW, Malat J, et al. Fungal sinusitis: diagnosis with CT and MR imaging. Radiology 1988; 169:439.
  47. Kaschke O, Rumor D, Jautzke G, et al. [Investigations on allergic fungal genesis of chronic rhinosinusitis]. Laryngorhinootologie 2002; 81:629.
  48. Schubert MS. Fungal rhinosinusitis: diagnosis and therapy. Curr Allergy Asthma Rep 2001; 1:268.
  49. Katzenstein AL, Sale SR, Greenberger PA. Pathologic findings in allergic aspergillus sinusitis. A newly recognized form of sinusitis. Am J Surg Pathol 1983; 7:439.
  50. Hamilos DL. Chronic rhinosinusitis: epidemiology and medical management. J Allergy Clin Immunol 2011; 128:693.
  51. Guo C, Ghadersohi S, Kephart GM, et al. Improving the detection of fungi in eosinophilic mucin: seeing what we could not see before. Otolaryngol Head Neck Surg 2012; 147:943.
  52. Javer AR, Genoway KA, Gervais M, et al. Fungal cultures in patients with allergic fungal rhinosinusitis: improving the recovery of potential fungal pathogens in the Canadian laboratory. J Otolaryngol 2007; 36:1.
  53. Lebowitz RA, Waltzman MN, Jacobs JB, et al. Isolation of fungi by standard laboratory methods in patients with chronic rhinosinusitis. Laryngoscope 2002; 112:2189.
  54. Montone KT, Livolsi VA, Lanza DC, et al. Rapid In-situ hybridization for dematiaceous fungi using a broad-spectrum oligonucleotide DNA probe. Diagn Mol Pathol 2011; 20:180.
  55. deShazo RD, Swain RE. Diagnostic criteria for allergic fungal sinusitis. J Allergy Clin Immunol 1995; 96:24.
  56. Hamilos DL. Allergic fungal rhinitis and rhinosinusitis. Proc Am Thorac Soc 2010; 7:245.
  57. Horner WE, Helbling A, Salvaggio JE, Lehrer SB. Fungal allergens. Clin Microbiol Rev 1995; 8:161.
  58. Morpeth JF, Rupp NT, Dolen WK, et al. Fungal sinusitis: an update. Ann Allergy Asthma Immunol 1996; 76:128.
  59. deShazo RD, O'Brien M, Chapin K, et al. A new classification and diagnostic criteria for invasive fungal sinusitis. Arch Otolaryngol Head Neck Surg 1997; 123:1181.
  60. Blitzer A, Lawson W, Meyers BR, Biller HF. Patient survival factors in paranasal sinus mucormycosis. Laryngoscope 1980; 90:635.
  61. Chakrabarti A, Sharma SC, Chandler J. Epidemiology and pathogenesis of paranasal sinus mycoses. Otolaryngol Head Neck Surg 1992; 107:745.
  62. Washburn RG, Kennedy DW, Begley MG, et al. Chronic fungal sinusitis in apparently normal hosts. Medicine (Baltimore) 1988; 67:231.
  63. Reddy CE, Gupta AK, Singh P, Mann SB. Imaging of granulomatous and chronic invasive fungal sinusitis: comparison with allergic fungal sinusitis. Otolaryngol Head Neck Surg 2010; 143:294.
  64. Ferguson BJ. Eosinophilic mucin rhinosinusitis: a distinct clinicopathological entity. Laryngoscope 2000; 110:799.
  65. Schubert MS. Allergic fungal sinusitis. Clin Rev Allergy Immunol 2006; 30:205.
  66. Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology 2012; 50:1.
  67. Peters AT, Spector S, Hsu J, et al. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol 2014; 113:347.
  68. Thomas WW 3rd, Harvey RJ, Rudmik L, et al. Distribution of topical agents to the paranasal sinuses: an evidence-based review with recommendations. Int Forum Allergy Rhinol 2013; 3:691.
  69. Huchton DM. Allergic fungal sinusitis: an otorhinolaryngologic perspective. Allergy Asthma Proc 2003; 24:307.
  70. Stonebraker AC, Schlosser RJ. Orbital volumetric analysis of allergic fungal sinusitis patients with proptosis before and after endoscopic sinus surgery. Am J Rhinol 2005; 19:302.
  71. Landsberg R, Segev Y, DeRowe A, et al. Systemic corticosteroids for allergic fungal rhinosinusitis and chronic rhinosinusitis with nasal polyposis: a comparative study. Otolaryngol Head Neck Surg 2007; 136:252.
  72. Sieskiewicz A, Olszewska E, Rogowski M, Grycz E. Preoperative corticosteroid oral therapy and intraoperative bleeding during functional endoscopic sinus surgery in patients with severe nasal polyposis: a preliminary investigation. Ann Otol Rhinol Laryngol 2006; 115:490.
  73. Hong SJ, Lee JK, Lee HS, et al. Availability of preoperative systemic steroids on endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis. Yonsei Med J 2014; 55:1683.
  74. Rupa V, Jacob M, Mathews MS, Seshadri MS. A prospective, randomised, placebo-controlled trial of postoperative oral steroid in allergic fungal sinusitis. Eur Arch Otorhinolaryngol 2010; 267:233.
  75. Gan EC, Thamboo A, Rudmik L, et al. Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations. Int Forum Allergy Rhinol 2014; 4:702.
  76. Bassichis BA, Marple BF, Mabry RL, et al. Use of immunotherapy in previously treated patients with allergic fungal sinusitis. Otolaryngol Head Neck Surg 2001; 125:487.
  77. Greenhaw B, deShazo RD, Arnold J, Wright L. Fungal immunotherapy in patients with allergic fungal sinusitis. Ann Allergy Asthma Immunol 2011; 107:432.
  78. Hall AG, deShazo RD. Immunotherapy for allergic fungal sinusitis. Curr Opin Allergy Clin Immunol 2012; 12:629.
  79. Marple B, Newcomer M, Schwade N, Mabry R. Natural history of allergic fungal rhinosinusitis: a 4- to 10-year follow-up. Otolaryngol Head Neck Surg 2002; 127:361.
  80. Doellman MS, Dion GR, Weitzel EK, Reyes EG. Immunotherapy in allergic fungal sinusitis: The controversy continues. A recent review of literature. Allergy Rhinol (Providence) 2013; 4:e32.
  81. DeYoung K, Wentzel JL, Schlosser RJ, et al. Systematic review of immunotherapy for chronic rhinosinusitis. Am J Rhinol Allergy 2014; 28:145.
  82. Khalil Y, Tharwat A, Abdou AG, et al. The role of antifungal therapy in the prevention of recurrent allergic fungal rhinosinusitis after functional endoscopic sinus surgery: a randomized, controlled study. Ear Nose Throat J 2011; 90:E1.
  83. Chan KO, Genoway KA, Javer AR. Effectiveness of itraconazole in the management of refractory allergic fungal rhinosinusitis. J Otolaryngol Head Neck Surg 2008; 37:870.
  84. Kinsella JB, Bradfield JJ, Gourley WK, et al. Allergic fungal sinusitis. Clin Otolaryngol Allied Sci 1996; 21:389.
  85. Kupferberg SB, Bent JP. Allergic fungal sinusitis in the pediatric population. Arch Otolaryngol Head Neck Surg 1996; 122:1381.
  86. Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines for the management of rhinosinusitis and nasal polyposis. Clin Exp Allergy 2008; 38:260.
  87. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; 152:S1.
  88. Fokkens W, Lund V, Bachert C, et al. EAACI position paper on rhinosinusitis and nasal polyps executive summary. Allergy 2005; 60:583.
  89. Seiberling K, Wormald PJ. The role of itraconazole in recalcitrant fungal sinusitis. Am J Rhinol Allergy 2009; 23:303.
  90. Rains BM 3rd, Mineck CW. Treatment of allergic fungal sinusitis with high-dose itraconazole. Am J Rhinol 2003; 17:1.
  91. Kupferberg SB, Bent JP 3rd, Kuhn FA. Prognosis for allergic fungal sinusitis. Otolaryngol Head Neck Surg 1997; 117:35.
  92. Patro SK, Verma RK, Panda NK, et al. Efficacy of preoperative itraconazole in allergic fungal rhinosinusitis. Am J Rhinol Allergy 2015; 29:299.
  93. Evans MO 2nd, Coop CA. Novel treatment of allergic fungal sinusitis using omalizumab. Allergy Rhinol (Providence) 2014; 5:172.
  94. Gan EC, Habib AR, Rajwani A, Javer AR. Omalizumab therapy for refractory allergic fungal rhinosinusitis patients with moderate or severe asthma. Am J Otolaryngol 2015; 36:672.