Steroids Recommended as Diagnostic Tool for Allergic Rhinitis

Systemic corticosteroids (steroids) are an important part of the medical arsenal used for the treatment of chronic rhinosinusitis with nasal polyps. These potent anti-inflammatory agents reduce the polyps' volume leading to a significant improvement in the patients nasal breathing and sense of smell. Systemic steroids also have an important role in the treatment of allergic fungal rhinosinusitis and, as an additional therapy to surgery, provide an essential medical remedy to their curb inflammation.

Recent studies have claimed that the vast majority of cases of chronic rhinosinusitis (CRS) represent an immune-mediated response to the presence of fungi. This position asserts that the term "allergic fungal rhinosinusitis" is a misnomer and that patients thought to have this disorder are merely a part of the larger group of patients with CRS. Some in the medical community propose to eliminate the term "allergic" and instead to use the term "eosinophilic fungal rhinosinusitis"(EFRS) to describe most patients who have CRS.

A team of researchers from Israel is challenging this new trend. Their experience is that patients with CRS do not represent a homogenous group while the traditional diagnostic criteria for allergic fungal rhinosinusitis (AFRS) defines a very distinct group of patients.

A new study compares the objective effects of preoperative high-dose systemic steroids on the radiographic and endoscopic appearance of allergic fungal rhinosinusitis and chronic rhinosinustis with nasal polyps. The authors of Systemic Corticosteroids for Allergic Fungal Rhinosinusitis and Chronic Rhinosinusitis with Nasal Polyposis: A Comparative Study, are Roee Landsberg, MD, Yoram Segev, MD, Ari DeRowe, MD, Edna Bash, Avi Khafif, MD, and Dan M. Fliss, MD, all from the Tel Aviv Sourasky Medical Center in Israel, affiliated to the Sackler Faculty of Medicine at Tel Aviv University in Tel Aviv, Israel. Their findings are to be presented at the 109th annual meeting and OTO EXPO of the American Academy of OtolaryngologyHead and Neck Surgery Foundation, being held Sept. 25-28, 2005 in Los Angeles.

This prospective study was conducted at the Tel Aviv Sourasky Medical Center in Israel during from 2001 to 2004. A total of 13 patients (four males, three females; mean age 25 years, range 14-38) suspected of having AFRS based on the acceptable criteria. Seven of these patients were treated according to the study protocol and comprised the AFRS group. All seven patients had nasal polyps; allergic mucin (histologically containing fungal hyphae and degranulating eosinophils) was harvested during surgery and identified in six patients.

Patients with chronic rhinosinusitis and nasal polyps were selected with complete or near complete nasal obstruction by polyps and absence of AFRS characteristics. Ten patients met that criteria (six males, four females; mean age 47 years, range 38-65).

Both groups of patients underwent computed tomographic (CT) scans and then received preoperative 1 mg/kg prednisone for 10 days. CT scans were repeated one day before surgery and compared with pretreatment scans (Lund-MacKay radiologic scoring system). The endoscopic appearance was recorded intraoperatively.

Following a course of high-dose prednisone, the mean Lund-MacKay radiologic score dropped from 16.5 to 4.3 (71 percent) for the AFRS group and from 18.4 to 14.1 (23 percent) for the CRSwNP group, a statistically significant difference. In addition, the post-steroid change for each group was also statistically significant.

Following steroid therapy, the endoscopic mucosal appearance was strikingly different between the two groups: all or almost all the polypoid mucosa that had occupied the nasal cavity and paranasal sinuses before steroid treatment in the AFRS patients had disappeared and all or almost all mucosal surfaces appeared normal. In the CRSwNP group, although it had significantly shrunken, most of the polypoid mucosa that had occupied the nasal cavity and paranasal sinuses before steroid treatment was still present. The polyps appeared denser and felt firmer than their pre-steroid state. The mucosa of the maxillary, frontal, and sphenoid sinuses appeared either normal or polypoid.

The study reveals that radiographic and mucosal responses of AFRS to systemic steroids are much greater compared to CRSwNP. Knowing that steroids have a major effect on the production, migration, and activation of eosinophils, the researchers speculate that eosinophils may play a key role in that response. In CRSwNP, nasal polyps are characterized by eosinophilic inflammation within the mucosa. In AFRS, however, as demonstrated by imaging and observed during surgery, large amounts of allergic mucin occupying the sinuses lumen and containing numerous eosinophils are the hallmark of the disease.

The results of this study do not support the concept that AFRS is a misnomer and that patients with AFRS merely constitute a part of the large group of CRS or eosinophilic rhinosinusitis patients. The findings do add radiographic and mucosal response to systemic steroids as distinctive characteristic of this unique disease. While newer studies contend that a positive fungal smear and degranulating eosinophils are not specific to AFRS, they believe their observations a useful clinical addition to its diagnosis. The research team suggests that a marked clinical and radiographic response to short term high-dose prednisone should become additional diagnostic criteria for AFRS.

Radiographic and mucosal responses of AFRS to systemic steroids are significantly greater compared to CRSwNP. The marked response to high-dose prednisone may serve as additional criteria for diagnosing AFRS. Targeting surgery to the location of residual disease following high dose steroids makes possible a minimally invasive endoscopic sinus surgery approach.