Allergic Fungal Sinusitis

Aaron I. Brescia and Allen M. Seiden

History

A 47-year-old man’s chief complaints are chronic nasal obstruction, repeated sinus infections, and a history of nasal polyps noted by his primary care physician. He complains of intermittent facial pain and pressure over both cheeks, thick postnasal drip, and sore throats, especially in the morning. He has received two 5-day courses of azithromycin for presumed infection over the past 12 months with little change in symptoms. In addition, he has been started on nasal steroid sprays and oral antihistamines for presumed allergic rhinitis. One week ago, he completed a 21-day course of oral fluoroquinolone therapy with perhaps a little improvement in his congestion. He has not previously been tested for allergies, has no history of asthma, and denies a history of aspirin sensitivity. He did undergo sinus surgery 5 years ago and seemed to feel better for 2 to 3 years, but his symptoms have gradually recurred. He does take medication for high blood pressure, but otherwise he is healthy and takes only a multivitamin.

On physical examination, the patient has normal visual acuity and extraocular movements remain intact, with no proptosis. However, he does have mild pseudohypertelorism. Examination of his nose reveals a midline septum, nasal polyps bilaterally, inferior turbinate hypertrophy, and very thick, pasty discharge from each middle meatus.

Differential Diagnosis—Key Points

1. Recurrent diffuse nasal polyposis represents a benign process and is closely associated with a variety of nasal pathologies, including allergic rhinitis, cystic fibrosis, allergic fungal rhinosinusitis, and bacterial rhinosinusitis, all of which need to be considered in the differential diagnosis. On histologic examination, benign respiratory polyp tissue exhibits inflammatory hallmarks of eosinophilia, lymphocytic infiltration, and hyperplastic stroma. Bilateral nasal polyps make the diagnosis of inverting papilloma less likely, though not impossible, and this diagnosis should be kept in mind as well.

2. Samter’s triad of aspirin sensitivity (flushing, pruritic rashes, rhinorrhea, wheezing, or frank anaphylaxis), asthma, and nasal polyposis can develop later in life and so is not necessarily precluded by a relatively recent onset in a 47-year-old patient. However, this patient denies a history of asthma and has taken aspirin without untoward side effects.