title: Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations.
abstract: BACKGROUND
  Allergic fungal rhinosinusitis (AFRS) is a subset of polypoid chronic rhinosinusitis that is characterized by the presence of eosinophilic mucin with fungal hyphae within the sinuses and a Type I hypersensitivity to fungi. The treatment of AFRS usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal medical regimen is still controversial. Hence, the purpose of this article is to provide an evidence-based approach for the medical management of AFRS.
  
  
  METHODS
  A systemic review of the literature on the medical management of AFRS was performed using Medline, EMBASE, and Cochrane Review Databases up to March 15, 2013. The inclusion criteria were as follows: patients >18 years old; AFRS as defined by Bent and Kuhn; post-sinus surgery; studies with a clearly defined end point to evaluate the effectiveness of medical therapy in postoperative AFRS patients.
  
  
  RESULTS
  This review identified and assessed 6 medical modalities for AFRS in the literature: oral steroids; topical steroids; oral antifungals; topical antifungals; immunotherapy; and leukotriene modulators.
  
  
  CONCLUSIONS
  Based on available evidence in the literature, postoperative systemic and standard topical nasal steroids are recommended in the medical management of AFRS. Nonstandard topical nasal steroids, oral antifungals, and immunotherapy are options in cases of refractory AFRS. No recommendations can be provided for topical antifungals and leukotriene modulators due to insufficient clinical research reported in the literature.
authors.affiliation: St Paul's Sinus Centre, Division of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Eng Cern
authors.initials: EC
authors.lastname: Gan
authors.forename: Andrew
authors.initials: A
authors.lastname: Thamboo
authors.forename: Luke
authors.initials: L
authors.lastname: Rudmik
authors.forename: Peter H
authors.initials: PH
authors.lastname: Hwang
authors.forename: Berrylin J
authors.initials: BJ
authors.lastname: Ferguson
authors.forename: Amin R
authors.initials: AR
authors.lastname: Javer
mesh_terms: D000935:Antifungal Agents / Q000627:therapeutic use; D003888:Desensitization, Immunologic; D004724:Endoscopy; D006801:Humans; D009181:Mycoses / Q000382:microbiology / Q000628:therapy*; D012221:Rhinitis, Allergic, Perennial / Q000382:microbiology / Q000628:therapy*; D012852:Sinusitis / Q000382:microbiology / Q000628:therapy*; D013256:Steroids / Q000627:therapeutic use
chemical_list: D000935:Antifungal Agents; D013256:Steroids
keywords: AFRS; allergic fungal rhinosinusitis; endoscopic sinus surgery; evidence-based medicine; medical management