Comparison of Postoperative use of Steroid or Itraconazole in cases of Allergic Fungal Rhinosinusitis

Jazeena, M (2020) Comparison of Postoperative use of Steroid or Itraconazole in cases of Allergic Fungal Rhinosinusitis. Masters thesis, Coimbatore Medical College, Coimbatore.


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INTRODUCTION: Allergic fungal rhino sinusitis is a subgroup of noninvasive fungal sinusitis. It results from an immunologic and allergic reaction of an atopic individual to the extra mucosal fungi in the sinuses. Bent and Khun developed a criteria for diagnosis of AFRS in 1994 which still holds best in diagnosing AFRS. Surgical removal of allergic fungal mucin is the main stay of treatment. Recurrence rate following functional endoscopic surgery found to be more, which made the introduction of post-operative adjunctive therapy. Medical therapy include systemic and topical steroids, systemic and topical antifungals and immunotherapy. Steroid is considered as standard medical treatment for AFRS. It reduces the recurrence along with reduction in mucosal changes and systemic IgE levels. As the recurrence of AFRS are mainly due to re exposure to fungal elements, antifungal agents can be considered as a good alternative. Our study intend to compare the efficacy of steroid and Itraconazole in preventing recurrence in patients with AFRS in post-operative period. REVIEW OF LITERATURE: Based on the journals I reviewed, Itraconazole in combination with steroid can be considered as an effective treatment for postoperative management of AFRS. Although most of the studies shows that steroids are better drugs in preventing recurrence in AFRS patients when compared to Itraconazole. For those patients whom steroid is contraindicated, we can consider Itraconazole as it can give 70% to 80% symptomatic relief and endoscopic clearance of disease. However, no enough studies are available to determine the effectiveness of itraconazole in the management of AFRS. AIMS AND OBJECTIVES: 1. To compare the effect of steroid Vs Itraconazole in preventing recurrence in patients with AFRS when given post-operatively. 2. To find out the effect of both drugs on absolute eosinophil count, serum IgE and mucosal changes of nose and paranasal sinuses post operatively. 3. To determine the preferred drug among these two in postoperative use for preventing recurrence. METHODOLOGY: Patients who were presenting to ENT OPD, Coimbatore Medical College hospital with nasal polyp, who are satisfying Bent and Khun’s diagnostic criteria for AFRS. Patients are randomly grouped into two containing 20 patients in each group. Absolute Eosinophil count, Serum IgE and diagnostic nasal endoscopy findings of all patients noted. Then all patients were taken up for surgery (FESS). One group (Group A) was given oral Itraconazole 100mg BD for 6 months post operatively. Steroid (Tab. Prednisolone 20mg BD for one month followed by topical steroids for five months after surgery) was given for the other group (Group B). LFT values for patients who were given Itraconazole was monitored every 2weeks. Absolute Eosinophil count, Serum IgE and diagnostic nasal endoscopy findings were noted and compared after completing 6 months of therapy. Diagnostic nasal endoscopic findings were given 4 scores according to the appearance of nasal mucosa. RESULTS: Maximum participant in our study population were between the age group of 25 to 45 years i.e., 6(15%), 5(13%) and 4(10%) patients were in the age group of 25 to 45 years Out of 20 patients in Group A, 12 were females and 8 were males. Similarly in Group B, 15 were females and 5 were males. All selected patients were satisfying all 5 major criterias of Bent and Khun’s criteria and few minor criterias. All 40 cases of AFRS showed elevated levels of AEC in the preoperative period. All were >550μg/L. The average pretreatment AEC in group A was 574.9μg/L and in group B was 581.6μg/L. Serum IgE levels were elevated in all cases. The mean preoperative serum IgE in group A was 864.5IU/mL and group B was 935.4IU/mL. The average post treatment levels of AEC in group A was 467.1μg/L and group B was 432μg/L. Both the groups showed reduction in AEC post treatment, of which group B showed a significant reduction in AEC post treatment. The average post treatment Serum IgE was also reduced in both groups but the significant drop noted in group B patients. Mean post treatment Serum IgE group A and Group B were 651.8 IU/mL and 562.7 IU/ mL respectively. Considering the Kupferberg endoscopic grading all 40 patients were endoscopic grade 4 preoperatively. In group A patients, endoscopic grade 1 was achieved in 5(25%) patients at the end of 6 months of post treatment. In group B patients, endoscopic grade 1 was achieved in 12 (60%) patients 6 months post treatment. Re occurrence of polypoidal mucosal changes not among few patients in both the groups but maximum reoccurrence seen in patients treated with itraconazole in post-operative period. CONCLUSION: This study suggest that both steroid and Itraconazole are effective drugs in preventing recurrence when used postoperatively. In terms of preventing recurrence, steroids are better drugs when compared to Itraconazole. A statistically significant difference in nasal cavity conditions was seen between the nasal endoscopic grades among both the groups. Steroid helps in making the cavity conditions better compared with those in whom Itraconazole was administered. The treatment of AFRS is divergent as different treatment protocols have been adopted in the past decade to overcome most frequently encountered complication i.e., recurrence of disease. Steroids (systemic/topical) have been claimed to increase the cure rates of AFRS by decreasing the recurrence rate with reduction in mucosal stage of disease and systemic IgE levels. Itraconazole by inhibiting enzyme lanosterol 14-alpha-demethylase decreases the synthesis of ergosterol and later considered as vital component of the fungal cell membrane hence reduces the fungal load in the postoperative period and Itraconazole has the best activity against Aspergillus and black moulds that typically causes fungal sinusitis. In the current study, patients treated with steroid had significant improvement in the symptoms and endoscopic grading at the end of six months. Patients of both the groups had significant reduction in AEC and serum IgE at the end of six months. Although both the drugs showed reduction in AEC and serum IgE post treatment, still symptomatic control of disease in the Steroid group was better than that of the Itraconazole group. 18Chan KO [et. al.] demonstrated the efficacy of Itraconazole in refractory AFRS found significant clinical improvement in 28% of cases. Itraconazole can be reserved for refractory cases. Even though Itraconazole is not as effective as steroid, it can be considered as an alternative for steroid in patients whom steroid is contra indicated as it gives 70 to 80% relief in symptoms.

Item Type: Thesis (Masters)
Additional Information: 221714252
Uncontrolled Keywords: Allergic Fungal Rhino Sinusitis, steroid, Itraconazole, Serum IgE, AEC, Recurrence.
Subjects: MEDICAL > Otolaryngology
Depositing User: Subramani R
Date Deposited: 15 Feb 2021 04:41
Last Modified: 15 Feb 2021 04:41

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