الفهرس 
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Abstract
SUMMARY
Allergic fungal rhino sinusitis (AFRS) is the most common form of fungal sinus disease, and the presence of nasal polyposis is one of the criteria required for its diagnosis.
Over the past 2 decades, AFRS has become increasingly defined, and it is now believed to represent an allergic reaction to aerosolized environmental fungi, usually of the dematiaceous species, in an immunocompetent host.
The five major criteria for AFRS are evidence of IgE-mediated hypersensitivity, nasal polyposis, characteristic CT findings, eosinophilic mucus, and positive fungal smear or culture. The minor criteria include asthma, unilateral predominance, radiographic bone erosion, fungal culture, charcot-Leyden crystals, and serum eosinophilia.
The most common management strategy for AFRS is the removal of allergic mucin and debris via functional endoscopic sinus surgery (FESS), but recurrence remains problematic, so a number of adjunctive medical modalities have been tried. Systemic corticosteroids appear most effective. Systemic corticosteroids given pre-operatively help to shrink polyps and decrease bleeding intra- operatively.
Postoperative systemic corticosteroids lead to improvement in symptoms and on endoscopy, but can have significant side-effects.
Topical delivery is advantageous as the risk of corticosteroid toxicity is minimised and inflammation is successfully suppressed for extended periods. A dose-response effect appears to exist. Antifungal drugs given systemically have not
proved effective for treatment of AFS, primarily because the drugs are not secreted into the nasal secretion.
The fungus is not invasive; and because the drugs are not secreted into the mucus, fungicidal levels are not achieved in the mucous lining of the nasal cavity and the paranasal sinuses. Another disadvantage in the use of systemic antifungal agents its side-effect profile is unfavourable, as is the cost.
Application of topical antifungals should achieve fungicidal concentrations in the nasal and paranasal sinus mucosa, eradicating the fungus and thus reducing fungal antigen load, so the use of topical fluconazole solution in the form of a spray or irrigant may significantly reduce the recurrence rate.
The favorable response to montelukast in AFS suggests a fundamental role for cysteinyl leukotrienes in its pathophysiology, which is not surprising given the strong presence of eosinophils in the disorder.