Allergic rhinitis (AR) and its co morbidities like asthma, sinusitis, and otitis media with effusion have a profound impact on the daily lives of children. Many of the problems go completely unnoticed as children often fail to share them at home or at school. It may result in day – time fatigue, as well as sleeplessness and impairment of cognition and memory. This may significantly affect the learning process and thus impacts on school performance and all these aspects upset the family . Children with AR are often embarrassed in school and have decreased social interaction that significantly hampers the process of learning and school performance . The adverse effects of some medications used for treatment often compoundthese problems . The risk factors of allergic rhinitis include the following dust, moulds, weather changes, pollen, pets and exposure to tobacco smoking.
Clinical manifestations can include rhinorrhea, nasal obstruction, headaches, itchy eyes and anosmia. Nasal polyposis is a very common finding ~ 90% cases . In approximately 50% of children with AFRS accumulation of mucin can experience sinus expansion resulting on facial dysmorphia and proptosis . It is not rare to have radiological evidence of orbital erosion in severe cases . Demographically, boys are more commonly affected than girls and African American children often present earlier and with more severe disease . Patients with it commonly are immunocompetent, and up to 50% of patients have comorbid allergic rhinitis or asthma . Bent and Kuhn Diagnostic Criteria is the most accepted by the experts and include characteristic CT imaging findings, evidence of eosinophilic mucus with positive fungal stain, and proven type I hypersensitivity by skin testing or serology (Table 1). Patients must meet all the major criteria for diagnosis, while the minor criteria serve to support the diagnosis and describe individual patients but are not used to make a diagnosis. The histopathologic findings in AFS are critical to the diagnosis. Most of the surgical specimens
demonstrated allergic mucin rich on eosinophils along with thecharacteristic Charcot-Leyden crystals. Fungi can be isolated from the mucin but does not invade the nasal and sinusal mucosa. Fungal cultures should be interpreted with caution. AFRS often is associated with dematiaceous fungi, being the most common isolation Aspergillus species .
Treatment of AFRS typically includes endoscopic sinus surgery to enlarge the sinus ostia and remove eosinophilic mucin. Saline irrigations are routinely used postoperatively to prevent mucin accumulation. Recent data supports the use of a short course of postoperative oral corticosteroids in the management of postoperative AFRS . Leukotriene modifiers and anti-inflammatory macrolide antibiotics are often employed to try to reduce steroid requirements, but it is unknown if these improve outcomes or reduce the need for revision surgery. A recent meta-analysis reported no statistically significant benefit of systemic or topical antifungal therapy over placebo in the treatment of chronic sinusitis . Complications from allergic fungal sinusitis are exceedingly rare but bacterial superinfection can lead to infectious sinusitis and less commonly to orbital abscess and cavernous sinus thrombosis. In summary, although AFRS is uncommon in the pediatric population a good clinician should be able to distinguish it from bacterial sinusitis, because management of the two differs considerably, and morbidity can be significant if treatment of AFRS is delayed.