Two hundred-ten consecutive patients with chronic sinusitis, of whom 101 were treated surgically, were studied. Fungal cultures of nasal secretions were positive in 202 (96%) of the patients. Candida albicans was cultured in 15.4% of patients, Alternaria in 44.3%, Penicillium in 43.3%, Cladosporium in 39%, and Aspergillus spp. in 29.5%; a wide range of other organisms were cultured less frequently. Allergic mucin (containing clusters or sheets of degenerating eosinophils) was found in 97 (96%) of the 101 surgical cases. Fungal elements (hyphae, destroyed hyphae, conidiae, and spores) were found histologically in 82 (81%) of the 101 surgical specimens. Allergic fungal sinusitis was diagnosed in 94 (93%) of the 101 surgical cases, based on histopathologic findings and culture results. An elevated IgE level to at least one fungal species was found in only 28% of 95 patients tested, and skin-prick tests were positive to at least one fungal allergen in only 25% of 179 patients tested.

Comment: The results of this study suggest that, among patients with chronic sinusitis, allergy to common airborne fungi appeared to be a causative factor in at least 93% of cases. Conventional tests for fungal allergy (e.g., IgE levels and skin-prick tests) failed to detect fungal allergy in the majority of patients with allergic fungal sinusitis. The research group that performed this study subsequently demonstrated that patients with chronic sinusitis have an exaggerated immune response to airborne fungi (J Allergy Clin Immunol 2004;114:1369-1375). They have also reported, in open (J Allergy Clin Immunol 2002;110:862-866) and double-blind (J Allergy Clin Immunol 2005;115:125-131) trials, that intranasal administration of the antifungal drug amphotericin B resulted in clinical improvement and a reduction in mucosal thickening. In the open trial, of 51 patients treated, 75% improved and 35% became disease-free.

In my experience, some patients with chronic sinusitis show marked improvement after identifying and avoiding allergenic foods. A few patients have shown a dramatic response to intravenous nutrient therapy (the Myers' cocktail; see Altern Med Rev 2002;7:389-403).

Ponikau JU, et al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc 1999;74:877-884.