Chronic Sinusitis? Think FUNGAL!

Chronic Sinusitis?  Think FUNGAL!

Dr. Weeks’ Comment:   Over the past 25 years, the great majority of my patients with chronic sinusitis have been misdiagnosed as suffering with bacterial infection when the real problem was a chronic fungal infection.  The Mayo Clinic has published on this but few doctors paid attention. Typically a fungal cause is only considered in immunocompromised patients  but a student of nature may have learned that any flower with a trumpet shaped blossom (like the easter lily) secretes anti-fungal chemical to maintain its vitality. Over use of anti-biotics aside (being fed to animals to enhance growth) the tragedy is that primary care doctors frequently don’t consider fungal infections in the case of sinusitis and so much suffering from headaches and congestion result.  Here below are some articles for consideration  as well as this post from 2011 which anyone with chronic sinusitis might appreciate. 

 

1.
Indian J Otolaryngol Head Neck Surg. 2014 Jan;66(Suppl 1):371-4. doi: 10.1007/s12070-012-0500-2. Epub 2012 Feb 19.

Candida kefyr in Invasive Paranasal Sinusitis.

Abstract

Fungi are being increasingly implicated in etio pathology of rhino sinusitis. Invasive fungal sinusitis occurring in diabetics and immunocompromised patients is notorious for its insidious onset, rapid intra cranial spread and tissue destruction. Candida as a cause of this invasive infection is infrequently reported in India. We report a rare species of Candida, Candida kefyr in a female diabetic patient presenting with invasive fungal sinusitis.

KEYWORDS:

Candida kefyr, Diabetic, Invasive fungal sinusitis

2.
Int Forum Allergy Rhinol. 2014 Apr;4(4):280-3. doi: 10.1002/alr.21299. Epub 2014 Feb 7.

Chronic granulomatous invasive fungal sinusitis: an evolving approach to management.

Abstract

BACKGROUND:

Chronic granulomatous invasive fungal sinusitis (CGIFS) is rare and a consensus on ideal management is lacking. We present an extensive case managed successfully with a conservative approach.

METHODS:

Case report and literature review.

RESULTS:

The patient presented with unilateral proptosis, papilledema, and headache. Imaging revealed an infiltrative process with extensive intracranial and intraorbital involvement. Biopsy showed fungal elements and granulomatous reaction consistent with CGIFS. The patient was managed with conservative surgery and long-term oral voriconazole.

CONCLUSION:

This case supports a conservative surgical approach in some patients with extensive CGIFS. Oral voriconazole is effective and has significant advantages over more toxic agents administered intravenously.

© 2014 ARS-AAOA, LLC.

KEYWORDS:

Aspergillus fumigatus, fungus diseases, papilledema, sinusitis, voriconazole

3.
J Assoc Physicians India. 2013 May;61(5):339-40.

Rhino-orbital-cerebral infection by Syncephalastrum racemosusm.

Abstract

Invasive rhino-sinusitis infection has been known to be caused by zygomycetes commonly belonging to the genera Rhizopus, Mucor and Rhizomucor. We report a middle aged diabetic gentleman who had invasive rhino-orbital-cerebral infection with Syncephalastrum racemosum. This genera belonging to zygomycetes group of fungi which usually causes skin and soft tissue infection but invasive infection with this fungus is rarely known.

4.
Laryngoscope. 2014 Jan 24. doi: 10.1002/lary.24608. [Epub ahead of print]

Invasive fungal sinusitis in a healthy athlete due to long-term anabolic steroid use.

Abstract

Invasive fungal rhinosinusitis is a potentially fatal infection that affects immunocompromised patients. Prognosis is generally poor despite aggressive medical and surgical treatments. We present the first reported case of invasive fungal sinusitis in a healthy 18-year-old male athlete who was taking anabolic steroids. The effects of excessive AAS use on the immune system are not fully understood, but there may be consequences at supraphysiological concentrations. This case demonstrates potential immunomodulatory effects of anabolic steroids and highlights a previously unknown cause of invasive fungal sinusitis.

Copyright © 2014 The American Laryngological, Rhinological, and Otological Society, Inc.

KEYWORDS:

Invasive fungal sinusitis, anabolic, aspergillosis, aspergillus, sinus, steroids, surgery

5.
Int Forum Allergy Rhinol. 2014 Apr;4(4):272-9. doi: 10.1002/alr.21292. Epub 2014 Jan 21.

Markers of disease severity and socioeconomic factors in allergic fungal rhinosinusitis.

Abstract

BACKGROUND:

Allergic fungal rhinosinusitis (AFRS) is a refractory subtype of chronic rhinosinusitis. There is a paucity of data investigating the association of epidemiologic markers of disease severity. The primary objective of this study is to evaluate components of disease severity with socioeconomic status and health care access.

METHODS:

A retrospective analysis was performed on patients diagnosed with AFRS by Bent and Kuhn criteria from 2000 to 2013. Severity of disease was measured by orbitocranial involvement, bone erosion, Lund-Mackay score, serum immunoglobulin E (IgE), and mold hypersensitivity. The North Carolina State Data Center provided county-specific socioeconomic and demographic data. Fisher’s exact test, Wilcoxon rank sum test, Pearson correlations, and multivariable linear regression models were used to explore associations between variables.

RESULTS:

Of 93 patients, 58% were African American and 39% Caucasian with a male:female ratio of 1.4:1 and average age at presentation of 29 years. Race, age, insurance status, and gender were not associated with severity of disease. Bone erosion was correlated with residence in counties with lower income per capita (p = 0.01). Patients with orbitocranial involvement resided in more rural counties (p = 0.01) with less primary care providers per capita (p = 0.02). Residence in counties with older or poorer quality housing was associated with a higher prevalence of bone erosion (p = 0.02).

CONCLUSION:

Within our cohort of patients residing in North Carolina, markers of disease severity (bone erosion and orbitocranial involvement) in AFRS were associated with lower income, rural counties, poor housing quality, and less health care access.

© 2014 ARS-AAOA, LLC.

KEYWORDS:

allergy, bone, chronic rhinosinusitis, demography, epidemiology, gender, mold, race, sinusitis

6.
Indian J Otolaryngol Head Neck Surg. 2013 Aug;65(Suppl 2):288-94. doi: 10.1007/s12070-011-0444-y. Epub 2012 Jan 6.

Comparison of efficacy of amphotericin B and itraconazole in chronic invasive fungal sinusitis.

Abstract

Management of invasive fungal sinusitis includes both surgery and antifungal chemotherapy. To compare the efficacy of amphotericin B and itraconazole used alone in the management of chronic invasive fungal sinusitis. A prospective randomized unblinded study was conducted in the Department of Otolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India during December 2006 to June 2008. 26 immunocompetent patients were randomly divided into two groups-group A-received amphotericin B and group I-received itraconazole in conventional doses. The response to treatment was judged on the basis of symptomatic and radiologic resolution. Seven patients had complete cure (5/16-gr I; 2/10-gr A); Eleven patients had persistent disease (7/16-group-I; 4/10 in group A); four relapses were noted (3/16 in group I and 1/10 in group A); 3 deaths occurred; one patient was lost to follow up. Relative risk analysis did not show any statistically significant difference between the two drugs as regards their efficacy. Itraconazole and amphotericin B both have been found to be equally efficacious in the management of invasive fungal sinusitis. Itraconazole however, has fewer side effects compared to amphotericin B.

KEYWORDS:

Antifungal agents, Immunocompetent, Invasive fungal sinusitis

7.
Int Forum Allergy Rhinol. 2014 Mar;4(3):196-9. doi: 10.1002/alr.21274. Epub 2014 Jan 10.

Impact of vitamin D deficiency upon clinical presentation in nasal polyposis.

Abstract

BACKGROUND:

The objective of this work was to determine if specific chronic rhinosinusitis with nasal polyps (CRSwNP) populations are at risk for vitamin D3 (VD3 ) deficiency and if VD3 levels correlate with radiographic measures of disease severity or eosinophilia.

METHODS:

This study was a retrospective review of an academic rhinology practice. CRSwNP patients who had VD3 levels and CT scan within 6 months of each other were included. CT scans were graded using Lund-Mackay scoring (LMS) and peripheral eosinophil counts were measured. Demographic data including race, gender, age, body mass index, atopic status, and presence of asthma were collected. CRSwNP was subdivided into allergic fungal rhinosinusitis (AFRS), aspirin-exacerbated respiratory disease (AERD), and other CRSwNP. Multivariate analysis was performed to examine correlations and control for confounding factors.

RESULTS:

Insufficient VD3 levels were found in 55% of all CRSwNP patients. VD3 correlated with African American race because nearly 80% of all African Americans had insufficient VD3 levels. Lower VD3 levels also correlated with more severe mucosal disease on CT scans as measured by LMS. There was no correlation between VD3 levels and age, gender, body mass index, atopy, asthma, or CRSwNP subtype.

CONCLUSION:

VD3 insufficiency/deficiency is common in CRSwNP patients, especially those of African American race. Lower levels of VD3 are associated with worse LMS on CT. The role of VD3 in CRSwNP warrants further investigation.

© 2014 ARS-AAOA, LLC.

KEYWORDS:

cholecalciferol, chronic rhinosinusitis, nasal polyposis, polyps, sinusitis, vitamin D, vitamin D deficiency

8.
Srp Arh Celok Lek. 2013 Sep-Oct;141(9-10):698-704.

[Allergic fungal sinusitis–new aspects of clinical features, laboratory diagnosis and therapy].

[Article in Serbian]

Abstract

Allergic fungal sinusitis (AFS) is a chronic non-invasive disease. Hypersensitive immune response is usually initiated by allergens of filamentous fungi Aspergillus, Penicillium, Cladosporium, Fusarium, Bipolaris, Curvularia and Alternaria. AFS is a clinical and immune analogue of the allergic bronchopulmonary aspergillosis (ABPA) as the sinus exudate resembles that of the bronchoalveolar lavage (BAL) in ABPA. Patients with AFS are usually immunocompetent, atopic and males. The most common symptoms are headache, fullness in the paranasal sinuses, and difficult breathing through the nose. Clinically, there is a chronic mucosal inflammation and histopathologic finding shows allergic mucin and eosinophils. Specific staining methods, Gomori’s Methenamine Silver (GMS) or periodic acid-Schiff (PAS), are used for microscopic visualisation of hyphae, which are, in addition to the isolated fungi, most reliable evidence of AFS. Computerized tomography (CT) of paranasal sinuses shows the areas of hyperdensity. In cases where AFS is complicated by the erosion of bone tissue, discontinuation of the sinus bone wall can be seen. Significant laboratory finding, which correlate highly with the AFS, are high immunoglobulin E (IgE) antibodies specific forfungi, detected by the skin prick test or in serum. Treatment is often surgical, and after removal of the allergic mucin, therapy involves oral and nasal corticosteroids, immunotherapy and locally applied antimycotics (with verified fungal etiology). During treatment, the total/specific IgE is monitored–concentration increases with the development of AFS, and decreases during the improvement process. Knowledge of the pathophysiological mechanisms of AFS is scarce, and represents the focus of further research in order to define an optimal diagnostic and therapeutic approach.

9.

[Diagnosis and treatment of unilateral allergic fungal sinusitis].

[Article in Chinese]
Chen F1Xu M2Liu X2Feng Y2Shi Z2Xue T2Qiao L2Qiu J2.

Abstract

OBJECTIVE:

To investigate the clinical and pathological manifestation, prognosis of unilateral allergic fungal sinusitis (AFS), and to analyze the characters and treatment paradigm of unilateral AFS.

METHOD:

Clinical and pathological information of 10 cases of unilateral AFS were analyzed. Nasal endoscopy, skin prick test, and visual analogue score (VAS) of severity of illness were taken before surgery. Mucosa membrane and inspissated secretion obtained during endoscopic surgery were stained with hematoxylin-eosin and silver hexosamine. Regular clean of sinus and intranasal steroid spray were taken after surgery.

RESULT:

Endoscopy showed that 5 cases had pale mucous membranes in the ipsilateral nasal cavity. Skin prick test was positive in all patients. Nasal CT scan demonstrated unilateral lesion in all 10 patients. In the involved sinus, all 10 patients had brown or yellow brown viscous secretion, which demonstrated eosinophilic amorphous mass with accumulation of eosinophils, Charcot-Leyden crystallization andfungal hyphae under microscope. The number of eosinophils in lamina propria of sinus mucosa membrane was 72 +/- 11/hpf. After follow-up for 16 to 26 months(mean 22 months), 9 cases were cured and 1 improved. The pre-operative VAS was 8.5 +/- 1.2, and the post-operative VAS was 1.1 +/- 1.0 (P < 0.01).

CONCLUSION:

The systemic and local allergic reaction may co-exist in unilateral AFS, in which local hypersensitivity may be the dominant reaction. Endoscopic sinus surgery and intranasal steroid spray are effective in the treatment of unilateral AFS.

10.
FP Essent. 2013 Dec;415:11-6.

Section one. Acute and chronic rhinosinusitis.

Abstract

Rhinosinusitis is one of the most common conditions seen by family physicians. Most cases are viral in nature and resolve spontaneously. When symptoms persist for 10 days or more or are accompanied by severe pain and fever, bacterial sinusitis may be present. Current guidelines recommend that acute bacterial sinusitis be treated with amoxicillin-clavulanate. Chronic bacterial sinusitis typically involves a change in the sinus ostia and microbiology. This rarely resolves with antibiotic treatment alone and often warrants surgical intervention. Fungalsinusitis is a rare condition seen more often in immunosuppressed individuals and manifests in severe symptoms along with possible neurologic findings.

Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.

12.
South Med J. 2013 Nov;106(11):642-8. doi: 10.1097/SMJ.0000000000000018.

Approaching chronic sinusitis.

Abstract

Chronic sinusitis is a common disease that encompasses a number of syndromes that are characterized by sinonasal mucosal inflammation. Chronic sinusitis can be defined as two or more of the following symptoms lasting for more than 12 consecutive weeks: discolored rhinorrhea, postnasal drip, nasal obstruction, facial pressure or pain, or decreased sense of smell. Chronic sinusitis is further classified as chronic sinusitiswith polyposis, chronic sinusitis without polyposis, or allergic fungal sinusitis using physical examination, and histologic and radiographic findings. Treatment methods for chronic sinusitis are based upon categorization of the disease and include oral and inhaled corticosteroids, nasal saline irrigations, and antibiotics in selected patients. Understanding the various forms of chronic sinusitis and managing and ruling out comorbidities are key to successful management of this common disorder.

13.

[Diagnosis and treatment of fungal ball rhino-sinusitis].

[Article in Chinese]

Abstract

OBJECTIVE:

To explore the diagnosis and treatment of the fungal ball rhino-sinusitis.

METHOD:

The clinical data of 128 cases with the fungal ball rhino-sinusitis in our hospital between September 2005 and January 2012 were retrospectively analyzed. All patients were accepted nasal endoscopic surgery and followed up after surgery. The diagnosis were confirmed by postoperative pathological examination.

RESULT:

The sinus of all patients epithelialized after the surgery from fourth to ninth weeks, one case recurred eight months later.

CONCLUSION:

Sinus CT scan and nasal endoscopy were very important to the diagnosis of the fungal ball rhino-sinusitis, and nasal endoscopic surgery is the most important treatment method to fungal ball rhino-sinusitis.

14.
Am J Otolaryngol. 2013 Nov-Dec;34(6):743-5. doi: 10.1016/j.amjoto.2013.07.016. Epub 2013 Sep 7.

Intranasal fungal (Alternaria) infection related to nasal steroid spray.

Abstract

During the past three decades intranasal corticosteroid sprays have been proven to be efficient and reasonably safe for the treatment of rhinitis,sinusitis and nasal polyposis. The adverse effects are generally localized and self-limited and rarely systemic or significant. We report an immunocompetent female treated with triamcinolone acetonide nasal spray for chronic rhinitis in whom an intranasal fungal infection with Alternaria species developed three months later. The infection was refractory to topical therapies alone, and was resolved with a combination of systemic and topical antifungal therapy. We also described the clinical manifestations of this rare infection and our therapeutic experience. In addition, we reviewed previous literature of fungal infections related to nasal corticosteroid sprays and compared them with our report.

© 2013 Elsevier Inc. All rights reserved.

15.
Saudi J Ophthalmol. 2012 Oct;26(4):419-26. doi: 10.1016/j.sjopt.2012.08.009.

Fungal rhinosinusitis and imaging modalities.

Abstract

This report provides an overview of fungal rhinosinusitis with a particular focus on acute fulminant invasive fungal sinusitis (AFIFS). Imaging modalities and findings that aid in diagnosis and surgical planning are reviewed with a pathophysiologic focus. In addition, the differential diagnosis based on imaging suggestive of AFIFS is considered.

KEYWORDS:

Acute fulminant invasive fungal sinusitis, Computed tomography, Fungal rhinosinusitis, Imaging, Magnetic Resonance Imaging

16.
J Laryngol Otol. 2013 Sep;127(9):867-71. doi: 10.1017/S0022215113001680. Epub 2013 Aug 13.

Allergic fungal sinusitis and eosinophilic mucin rhinosinusitis: diagnostic criteria.

Abstract

BACKGROUND:

Chronic sinusitis is one of the most common otolaryngological diagnoses. Allergic fungal sinusitis and eosinophilic mucin rhinosinusitis can easily be misdiagnosed and treated as chronic sinusitis, causing continuing harm.

AIM:

To better identify and characterise these two subgroups of patients, who may suffer from a systemic disease requiring multidisciplinary treatment and prolonged follow up.

METHODS:

A retrospective, longitudinal study of all patients diagnosed with allergic fungal sinusitis or eosinophilic mucin rhinosinusitis within one otolaryngology department over a 15-year period.

RESULTS:

Thirty-four patients were identified, 26 with eosinophilic mucin rhinosinusitis and 8 with allergic fungal sinusitis. Orbital involvement at diagnosis was commoner in allergic fungal sinusitis patients (50 per cent) than eosinophilic mucin rhinosinusitis patients (7.7 per cent; p < 0.05). Asthma was diagnosed in 73 per cent of eosinophilic mucin rhinosinusitis patients and 37 per cent of allergic fungal sinusitis patients.

CONCLUSION:

Allergic fungal sinusitis and eosinophilic mucin rhinosinusitis have the same clinical presentation but different clinical courses. The role of fungus and the ability to confirm its presence are still problematic issues, and additional studies are required.

18.
Clin Exp Allergy. 2013 Aug;43(8):835-49. doi: 10.1111/cea.12118.

Fungal rhinosinusitis: what every allergist should know.

Abstract

The interaction between fungi and the sinonasal tract results in a diverse range of diseases with an equally broad spectrum of clinical severity. The classification of these interactions has become complex, and this review seeks to rationalize and simplify the approach to fungal diseases of the nose and paranasal sinuses. These conditions may be discussed under two major headings: non-invasive disease (localized fungalcolonization, fungal ball and allergic fungal rhinosinusitis) and invasive disease (acute invasive rhinosinusitis, chronic invasive rhinosinusitis and granulomatous invasive rhinosinusitis). A diagnosis of fungal rhinosinusitis is established by combining findings on history, clinical examination, laboratory testing, imaging and histopathology. The immunocompetence of the patient is of great importance, as invasive fungal rhinosinusitis is uncommon in immunocompetent patients. With the exception of localized fungal colonization, treatment of all forms of fungal rhinosinusitis relies heavily on surgery. Systemic antifungal agents are a fundamental component in the treatment of invasive forms, but are not indicated for the treatment of the non-invasive forms. Antifungal drugs may have a role as adjuvant therapy in allergic fungal rhinosinusitis, but evidence is poor to support recommendations. Randomized controlled trials need to be performed to confirm the benefit of immunotherapy in the treatment of allergic fungal rhinosinusitis. In this article, we will summarize the current literature, addressing the controversies regarding the diagnosis and management of fungal rhinosinusitis, and focussing on those aspects which are important for clinical immunologists and allergists.

© 2013 Blackwell Publishing Ltd.

19.
Indian J Med Microbiol. 2013 Jul-Sep;31(3):266-9. doi: 10.4103/0255-0857.115634.

Fungal rhinosinusitis: a prospective study in a University hospital of Uttar Pradesh.

Abstract

BACKGROUND:

To assess the purpose of fungal rhinosinusitis in a University hospital and to correlate histopathological findings with culture results for accurate clinical classification of the disease.

MATERIALS AND METHODS:

One-hundred suspected patients were included in the study. Data was collected in a brief predetermined format. Samples like nasal lavages, sinus secretions, and tissue specimens were processed and examined by microbiology culture using recommended techniques. Slide culture was done to observe the microscopic morphology. Histopathological examination was done by H and E stain and PAS stain for classification.

RESULTS:

Out of 100 cases of rhinosinusitis, 21 cases were culture-positive for fungal rhinosinusitis. On the basis of histopathological findings, 14 cases (66.67%) were found to be of non-invasive fungal rhinosinusitis. Aspergillus flavus was the most common fungal isolate.

CONCLUSION:

Mycological profile of rhinosinusitis in Lucknow was thus evaluated. Histopathological and microbiological findings reported 21 cases of fungal rhinosinusitis among 100 suspected cases of rhinosinusitis.

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20.
Indian J Med Microbiol. 2013 Apr-Jun;31(2):196-8. doi: 10.4103/0255-0857.115233.

A case report of an uncommon phaeoid fungal infection in nasal polyposis and review of literature.

Abstract

Nasal polyposis is an inflammatory condition of mucous membrane of the nose and paranasal sinuses with unknown aetiology. Massive nasal polyps can obstruct the nasal cavity causing discomfort and lowered quality of life. Thus, aetiological diagnosis is important for treatment, especially in recurrent nasal polyposis. We present a rare case of pansinusitis with bilateral ethmoidal polyps caused by an unusual phaeoid fungus Fonsecaea pedrosoi in a 65-year-old immunocompetent male from a rural background. The diagnosis was made by endoscopic nasal examination; high resolution computed tomography of the paranasal sinuses, detection of fungal hyphae in 10% potassium hydroxide wet mount and culture.

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21.
Allergy Rhinol (Providence). 2013 Spring;4(1):e32-5. doi: 10.2500/ar.2013.4.0045.

Immunotherapy in allergic fungal sinusitis: The controversy continues. A recent review of literature.

Abstract

Allergic fungal sinusitis (AFS), also referred to as allergic fungal rhinosinusitis (AFRS), is a noninvasive, eosinophilic form of recurrent chronic allergic hypertrophic rhinosinusitis. AFS has distinct clinical, histopathological, and prognostic findings that differentiate it from other forms ofsinusitis. The core pathogenesis and optimum treatment strategies remain debated. Concerns surround the use of immunotherapy for AFS because allergen-specific immunoglobulin G (IgG) induced by immunotherapy could theoretically incite a Gell and Coombs type III (complex mediated) reaction. Type I hypersensitivity is established by high serum levels of allergen-specific IgE to various fungal antigens and positive Bipolaris skin test results. Type III hypersensitivity is established by an IgG-mediated process defined by the presence of allergen-specific IgG that forms complexes with fungal antigen inducing an immunologic inflammatory response. These reveal the multiple immunologic pathways through which AFS can impact host responses. Recent literature establishing benefits of fungal immunotherapy and no evidence of type III-mediated reactions, severe local reactions, or delayed reactions, indicate that application of AFS desensitization is a reasonable therapeutic strategy for this difficult to manage entity. Our review should encourage further clinical acceptance of AFS desensitization because the existing literature on this subject shows benefits of fungal immunotherapy and no evidence of type III-mediated reactions, severe local reactions, or delayed reactions.

KEYWORDS:

Allergic fungal sinusitis, chronic rhinosinusitis, eosinophilic mucus, literature review

22.
Am J Rhinol Allergy. 2013 May-Jun;27 Suppl 1:S28-30. doi: 10.2500/ajra.2013.27.3892.

Chapter 8: Invasive fungal rhinosinusitis.

Abstract

Invasive fungal rhinosinusitis (IFRS) is a disease of the paranasal sinuses and nasal cavity that typically affects immunocompromised patients in the acute fulminant form. Early symptoms can often mimic rhinosinusitis, while late symptoms can cause significant morbidity and mortality. Swelling and mucosal thickening can quickly progress to pale or necrotic tissue in the nasal cavity and sinuses, and the disease can rapidly spread and invade the palate, orbit, cavernous sinus, cranial nerves, skull base, carotid artery, and brain. IFRS can be life threatening if left undiagnosed or untreated. While the acute fulminant form of IFRS is the most rapidly progressive and destructive, granulomatous and chronic forms also exist. Diagnosis of IFRS often mandates imaging studies in conjunction with clinical, endoscopic, and histopathological examination. Treatment of IFRS consists of reversing the underlying immunosuppression, antifungal therapy, and aggressive surgical debridement. With early diagnosis and treatment, IFRS can be treated and increase patient survival.

23.
Am J Rhinol Allergy. 2013 May-Jun;27 Suppl 1:S26-7. doi: 10.2500/ajra.2013.27.3891.

Chapter 7: Allergic fungal rhinosinusitis.

Abstract

Allergic fungal rhinosinusitis (AFRS) is a type of chronic rhinosinusitis in which patients classically exhibit nasal polyps, type I IgE-mediated hypersensitivity, characteristic findings on computed tomography scans, eosinophilic mucin, and positive fungal stain. New research has sought to further understand the pathophysiology of AFRS. However, this has also led to debate about the classification and predominance of this interesting disease process. Historically, patients with AFRS are immunocompetent. The disease is most prevalent in the southeast and south central United States and typically presents with sinus pressure, hyposmia, and congestion. Radiographically, cases of AFRS have a distinct appearance, often exhibiting unilateral heterogeneously dense material, which may erode and expand the paranasal sinus bony walls. Treatment typically consists of surgery, sinonasal irrigations, and topical and systemic steroids, all with the effort to decrease the fungal load and antigenic response. Immunotherapy is also often included in the treatment regimen for AFRS.

24.

[Analysis on therapeutic efficacy of different approaches for treating fungal maxillary sinusitis].

[Article in Chinese]

Abstract

OBJECTIVE:

To compare the response of simple endoscopic surgery and endoscopic surgery plus small windows through canine fossa surgery for fungal maxillary sinusitis.

METHOD:

Twenty-five patients were applied the endoscopic surgery plus small windows through Canine fossa surgery as the treatment group, and the other 25 were applied the simple endoscopic surgery as control.

RESULT:

During a follow up for 1-2 years, the effect of fungal maxillary sinusitis under endoscopic by dual approach is superior to simple endoscopic. There were obvious differences between the two groups(chi2 = 4.268, P < 0.05).

CONCLUSION:

Endoscopic surgery plus small windows through canine fossa surgery for fungal maxillary sinusitis can fully expose maxillary sinus cavity,destroy the abnormal tissues completely, change the low oxygen environment, ensure the normal physiological function of maxillary sinus mucosa, and really achieve radical minimally invasive purpose.

25.
Eur Arch Otorhinolaryngol. 2013 Nov;270(12):3095-8. doi: 10.1007/s00405-013-2449-5. Epub 2013 Mar 28.

The prevalence of allergic fungal rhinosinusitis in sinonasal polyposis.

Abstract

Allergic fungal sinusitis (AFS) is a noninvasive form of fungal rhinosinusitis with a prevalence of 6-9 % among all rhinosinusitis cases requiring surgery. The fungi causing AFRS have a great diversity and regional variation in the incidence of AFS has been reported worldwide. The aim of this study was to evaluate the prevalence of AFS among rhinosinusitis patients in the north east of Iran. In a prospective cross-sectional study 127 patients with sinonasal polyposis who were candidates for surgery were recruited. All cases were evaluated by sinonasal CT scan, Prick test for common regional allergens, total serum immunoglobulin E (IgE) level, and allergic mucin culture for fungi in suspected cases. Data analyses were done using SPSS version 13.0. Their mean age was 37.4 ± 11.6 years, the male-to-female ratio was 69/58. Eleven patients (9.45 %) met the AFS criteria. Nine cases had a positive culture for Aspergillus specimen and three for Alternaria. Prick test was positive for at least one allergen in 28 cases (22.05 %). The most common allergen was weed. The total IgE level was significantly higher in AFS patients. This study showed the prevalence of AFS among patients with nasal polyposis to be 9.45 %.

27.
Laryngoscope. 2013 Jul;123(7):1583-7. doi: 10.1002/lary.23978. Epub 2013 Feb 16.

Invasive fungal rhinosinusitis: a 15-year experience with 29 patients.

Abstract

OBJECTIVES/HYPOTHESIS:

Document a 15-year experience with 29 cases of acute invasive fungal rhinosinusitis (AIFR) and evaluate factors predictive of disease clearance and overall survival.

STUDY DESIGN:

Case series with chart review.

METHODS:

Patients were identified by review of department billing records between 1995 and 2010. Medical records were reviewed for patient demographics, disease characteristics, clinical course including surgical and medical therapy, treatment outcomes, and long-term survival.

RESULTS:

Twenty-nine patients with AIFR were identified. Causes of immunosuppression included hematologic malignancy (n=16), diabetes (n=12), medication (n=10), and acquired immunodeficiency syndrome (n=1), with 10 patients having multiple causes of immunosuppression. Facial pain, swelling and orbital symptoms were the most common presenting symptoms. Fungal organisms included Mucor (n=18) and Aspergillus (n=10) species, with one patient infected with both. Disease-specific survival (DSS) from AIFR was 57%. Intracranial (P=.01) and ethmoid sinus (P=.05) involvement were significantly linked with short-term disease-related mortality. Overall survival (OS) at 6 months was 18%. For OS, intracranial involvement (hazard ratio [HR], 4.47; 95% confidence interval [CI], 1.51-13.22) and cranial neuropathy at presentation (HR, 3.2; 95% CI, 1.3-8.2) were significantly associated with shortened survival. Of the five patients surviving >6 months, two developed long-term major sinonasal complications.

CONCLUSIONS:

DSS and OS remain low for patients with AIFR. Extensive surgical resection in patients with these poor prognostic signs should be considered carefully in light of their poor survival. Long-term survivors are at significant risk of sinonasal complications and should be followed closely.

Copyright © 2012 The American Laryngological, Rhinological and Otological Society, Inc.

PMID:

 23417294

[PubMed – indexed for MEDLINE]

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28.
J Laryngol Otol. 2013 Mar;127(3):274-8. doi: 10.1017/S0022215112003179. Epub 2013 Feb 6.

Isolated primary frontal sinus aspergillosis: role of endonasal endoscopic approach.

Abstract

BACKGROUND:

Frontal sinus involvement in aspergillosis associated with the nose and paranasal sinuses is a common occurrence, but the incidence of primary frontal sinus aspergillosis is rare, and there are few reports in the English literature. Objective: This study aimed to evaluate the role of the endonasal endoscopic surgical approach for isolated primary frontal sinus aspergillosis.

METHOD:

This paper describes a retrospective study of 16 cases of primary frontal sinus aspergillosis. The patients had presented to the out-patient services of the Department of Otolaryngology and Head and Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India, between January 1999 and July 2011.

RESULTS:

The overall success rate of the endonasal endoscopic approach was 82.25 per cent. The disease recurred in three patients and was subsequently managed using the modified Lothrop procedure.

CONCLUSION:

Minimally invasive endonasal endoscopic sinus surgery was found to be an effective and a safe approach for managing primary frontal sinus aspergilloma, even in cases with larger bony defects involving the posterior table of the frontal sinus.

30.
Zhonghua Bing Li Xue Za Zhi. 2012 Oct;41(10):662-6. doi: 10.3760/cma.j.issn.0529-5807.2012.10.004.

[Clinicopathologic study of invasive fungal rhinosinusitis caused by Aspergillus and Mucorales].

[Article in Chinese]

Abstract

OBJECTIVE:

To compare the differences in clinicopathologic features of invasive fungal rhinosinusitis caused by Aspergillus and Mucorales, and to discuss the pathogenesis of tissue injury induced by these two kinds of fungi.

METHODS:

The clinical and pathologic features of 19 patients with invasive fungal rhinosinusitis due to Aspergillus (group A) and 16 patients with invasive fungal rhinosinusitis due to Mucorales (group M) were retrospectively reviewed. HE, PAS and GMS stains were performed on all the paraffin-embedded tissues. The diagnosis was confirmed by histologic examination and microbiological culture results.

RESULTS:

Amongst the group A patients, the clinical course was acute in 4 cases and chronic in 15 cases. Thirteen cases had underlying predisposing conditions, including diabetes (number = 4), malignant tumor (number = 5), history of trauma (number = 1) and radical maxillary sinus surgery (number = 3). Follow-up information was available in 13 patients. Seven of them died, 4 due to fungal encephalopathy and 3 due to underlying diseases. Amongst the group M patients, the clinical course was acute in 14 cases and chronic in 2 cases. Fourteen cases had underlying predisposing conditions, including diabetes (number = 8), malignant tumor (number = 5) and history of wisdom tooth extraction (number = 1). Follow-up information was available in 14 patients. Four of them died of fungal encephalopathy. There was significant difference in clinical onset between the two groups (P = 0.01). There was however no difference in terms of underlying predisposing conditions and disease mortality. Histologically, the microorganisms in group A patients formed fungal masses and attached to the mucosal surface, resulting in necrotic bands (11/19). Epithelioid granulomas were conspicuous but multinucleated giant cells were relatively rare. Deep-seated necrosis, granulomatous inflammation against fungal organisms (3/19) and vasculitis with thrombosis (4/19) were not common. On the other hand, large areas of geographic necrosis involving deep-seated tissue could be seen in group M patients (13/16). Isolated multinucleated giant cells were commonly seen. Granulomatous inflammation against fungal organisms were identified (16/16). Vasculitis and thrombosis were also observed (10/16).

CONCLUSIONS:

The invasiveness of Mucorales is remarkable; and when it causes invasive fungal rhinosinusitis, the clinical course is often acute and large areas of tissue necrosis can be seen. The invasiveness of Aspergillus in tissue is relatively mild. Granulomas are more common and the disease often runs a chronic clinical course. There is however no significant difference in long-term mortality. The pathogenesis may be related to the different components of the fungi.

31.
Laryngoscope. 2013 May;123(5):1112-8. doi: 10.1002/lary.23912. Epub 2013 Jan 8.

Survival outcomes in acute invasive fungal sinusitis: a systematic review and quantitative synthesis of published evidence.

Abstract

OBJECTIVES/HYPOTHESIS:

Acute invasive fungal sinusitis (AIFS) is an aggressive and often fatal infection. Despite improvements in medical and surgical therapy, survival remains limited and the factors that contribute to patient outcomes remain poorly understood. The current study systematically reviews and quantitatively synthesizes the published literature to characterize prognostic factors associated with survival.

STUDY DESIGN:

Systematic review.

METHODS:

Fifty-two studies comprising a total of 807 patients met inclusion criteria and were used for analysis of treatment, presentation, and outcomes. Univariate and multivariate logistic regression was used to identify prognostic factors.

RESULTS:

All studies were classified as level 4 evidence, as per definitions provided by the Oxford Center for Evidence-Based Medicine. The most common presenting symptoms of patients with AIFS were facial swelling (64.5%), fever (62.9%), and nasal congestion (52.2%). Most patients were treated with a combination of intravenous antifungal medication and surgery. The overall survival rate was 49.7%. On univariate analysis, poor prognosis was associated with renal/liver failure, altered mental status, and intracranial extension. Patients who were diabetic, had surgery, or received liposomal amphotericin B had an improved chance of survival. On multivariate analysis, advanced age and intracranial involvement were identified as independent negative prognostic factors. Positive prognostic factors again included diabetes and surgical resection.

CONCLUSIONS:

The overall mortality of patients with AIFS remains high, with only half of the patients surviving. Diabetic patients appear to have a better overall survival than patients with other comorbidities. Patients who have intracranial involvement, or who do not receive surgery as part of their therapy, have a poor prognosis.

LEVEL OF EVIDENCE:

N/A.

Copyright © 2013 The American Laryngological, Rhinological, and Otological Society, Inc.

32.
Clin Experiment Ophthalmol. 2013 Aug;41(6):567-76. doi: 10.1111/ceo.12055. Epub 2013 Jan 24.

Neuro-ophthalmology of invasive fungal sinusitis: 14 consecutive patients and a review of the literature.

Abstract

BACKGROUND:

Invasive fungal sinusitis is a rare condition that usually occurs in immunocompromised patients and often presents as an orbital apex syndrome. It is frequently misdiagnosed on presentation and is almost always lethal without early treatment.

DESIGN:

Retrospective case series of 14 consecutive patients with biopsy-proven invasive fungal sinusitis from four tertiary hospitals.

PARTICIPANTS:

Fourteen patients (10 men and 4 women; age range 46-82 years).

METHODS:

Retrospective chart review of all patients presenting with invasive fungal sinusitis between 1994 and 2010 at each hospital, with a close analysis of the tempo of the disease to identify any potential window of opportunity for treatment.

MAIN OUTCOME MEASURES:

Demographic data, background medical history (including predisposing factors), symptoms, signs, radiological findings, histopathological findings, treatment approach and subsequent clinical course were recorded and analysed.

RESULTS:

Only one patient was correctly diagnosed at presentation. Only two patients were not diabetic or immunocompromised. The tempo was acute in two patients, subacute in nine patients and chronic in three patients. In the subacute and chronic cases, there was about 1 week of opportunity for treatment, from the time there was a complete orbital apex syndrome, and still a chance for saving the patient, to the time there was central nervous system invasion, which was invariably fatal. Only two patients survived – both had orbital exenteration, as well as antifungal drug treatment.

CONCLUSIONS:

Invasive fungal sinusitis can, rarely, occur in healthy individuals and should be suspected as a possible cause of a progressive orbital apex syndrome.

© 2012 The Authors. Clinical and Experimental Ophthalmology © 2012 Royal Australian and New Zealand College of Ophthalmologists.

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