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Allergic Fungal Rhinosinusitis in Children

An ll-year-old white boy was referred for evaluation of severe, chronic, right-sided nasal congestion of 2 years' duration. He had a long history of allergic rhinitis treated with immunotherapy, nasal steroids, antihistamines, and topical nasal decongestants. As the patient's nasal congestion had worsened over the previous several months, he was treated with a IO-day course of prednisone, 3 courses oforal antibiotics, and saline irrigations without significant relief. Physical examination revealed thick bilateral nasal drainage and the presence of an allergic crease over the nasal dorsum. Nasal endoscopy demonstrated severe bilateral turbinate edema despite decongestion. In the right maxillary antrum and ethmoid bullae, thick brown mucin and polyposis were identified. Computed tomography (CT) of the patient's sinuses showed heterogeneous opacification of the right maxillary, ethmoid, and sphenoid sinuses and the frontoethmoid recess (figure). The right lamina papyracea bowed laterally into the orbit. The patient underwent right-sided endoscopic sinus surgery, at which time thick, rubbery material was debrided from the maxillary sinus and anterior and posterior ethmoid cavities. Postoperatively, he was treated with 6 weeks of oral steroids and topical medications, and his symptoms resolved. He resumed treatment for allergic rhinitis under the care of his allergist. Allergic fungal rhinosinusitis (AFRS) is a noninvasive fungal sinusitis that encompasses just one arm of a wide spectrum of fungal sinus disease. AFRS is not as well described as acute and chronic bacterial sinusitis, as AFRS has only been recognized as a distinct pathologic entity during the past 3 decades. Figure. Allergicfungalsinusitis ischaracterized byunilateral sinus opacification with central hyperattenuation and heterogeneous density withinthesinuses.