FUNGAL SINUSITIS

Dr. Abinayaah Suresh

Associate professor of ENT

SMMCH & RI

Causative organism

​

• Aspergillus
• Mucor
• Candida
• Coccidiodomycosis
• Blastomycosis
• Fusarium

​

​

​

​

• Fungal sinusitis is a disease characterized by inflammation of Sinus mucosa due to fungal infection.

​

• It is commonly seen in immunocompromised or immunocompetant individual.

​

Causative factors

​

• Diabetic and immunocompromised patients.
• Patients with chronic renal failure.
• Chemotherapy.
• Prolonged use of nasal steroid spray.
• Prolonged systemic steroids.

​

​

Classification

​

• Invasive

Acute Invasive Fungal Sinusitis

Chronic Invasive Fungal Sinusitis

• Non Invasive

Fungus Balls

Saprophytic Fungal Infection

Allergic Fungal Rhinosinusitis

Acute Invasive Fungal Sinusitis

Etiology: The most common fungi are aspergillus species

and mucorales (mucormycosis).

• Mucormycosis: It is more common in diabetics. Fungal elements are broad, ribbon-like (10–15 mm), irregular and rarely septated.

b. Aspergillus: This species have narrow hyphae with regular septations and 45°branching.

​

Clinical features:

​

Acute clinical picture: It includes palatal erosion, impairment of vision, limitations in extraocular movements, fever, nasal and facial anesthesia and nasal necrosis.

� Mucopurulence: It is variable depending on the neutropenia of the host.

• Investigations: The investigations are as follows:

a. CBC in immunosuppressed patients may show neutropenia or evidence of left shift.

b. Coagulation profile includes platelets, bleeding time, prothrombin time and partial thromboplastin time. �c. Blood sugar is found raised in invasive fungus especially in mucormycosis

d. In culture an endoscopic aspirate culture is done with immediate fungal stains.

e. In biopsy if fungal stains are negative and suspicion is strong then biopsy with immediate frozen section and

fungal stains are done. Coagulation abnormalities if any are corrected before biopsy.

f. CT scan: A coronal CT scan is the minimum requirement of any fungal sinus surgery. – Axial scans provide additional information for the funguses of frontal and sphenoidal sinuses. Contrast studies are ordered if invasive fungus shows bony erosion, intracranial or orbital extension.

Treatment: Attempts must be made to reverse the immunocompromised status by controlling its cause,

​

Conservative debridement: Repeated conservative debridement (removal of necrotic tissue) may be needed in operative candidates, whose immunocompromised state can be reversed. Orbital exenteration should be avoided, when patient is not blind, even if there is involvement of the orbit. In cases of bone marrow transplant, when ingraft fails-immunocompromised mised state cannot be reversed and heroic surgeries are futile and must not be done.

​

Antifungal agents: The systemic and topical antifungal agents appropriate for the cultured fungus must be started immediately. Intravenous amphotericin B is usually started while awaiting fungal report. Ketoconazole and itraconazole: If Pseudallescheria boydii grows on culture.

Chronic Invasive Fungal Sinusitis

Causative fungi: A. Flavus (most common), A. Fumigatus, �Alternaria, P. Boydii, Sporothrix schenckii.

Types:

There are two types of chronic indolent invasive fungal sinusitis and both progress over weeks to months to years.

a. Granulomatous: It is common in Sudan and infects immunocompetent patients.

b. Nongranulomatous: It occurs in immunocompromised patients.

​

Diagnosis: Fungal culture and biopsy with special fungus stains confirm the diagnosis.

• Treatment: It consists of Repeated courses of antifungal therapy. � Surgical debridement.
• Attempts to control the cause of immunocompromise.

Fungus Balls

Causative fungal species: The fungi presenting with balls are A. Flavus, A. Fumigatus, Alternaria and Mucor.

​

Sites: Maxillary sinus is most commonly involved followed in descending frequency by sphenoid, ethmoid and the frontal.

​

Clinical features: This noninvasive fungus may remain asymptomatic for months to years but may become invasive if the patient becomes immunocompromised. It may present with facial pain and cacosmia.

​

Diagnosis: It is usually diagnosed at surgery and suspected on CT scans.

Culture may be negative but fungus can be seen with special stains.

CT scan: Fungus balls show total or partial sinus opacification (hyperdense area) and rarely bony erosion.

• Treatment: Usually no antifungal therapy is required. The recurrence after surgical removal is uncommon.

Allergic Fungal Rhinosinusitis

The manifestations of this noninvasive fungus occur because of a hypersensitivity response by the patient to the fungus. It responds to systemic steroids.

​

Etiology: Dematiaceous (darkly pigmented) fungal species include Alternaria, Bipolaris, and Curvularia.

​

Clinical features: Allergic fungal rhinosinusitis (AFRS) is found in cases of allergy, polyps and allergic mucin nasal casts.

​

Laboratory:

• Eosinophilia.
• Total immunoglobulin IgE is raised along with fungus specific IgE and IgG, which are difficult to evaluate as many fungi cause AFRS.
• In quiescent AFRS, total IgE may be normal.
• CT scan: AFRS shows heterogeneity of tissue densities within the sinuses. Post contrast MRI shows fungal growth with changes of sinusitis

Histopathology: Hyphae are seen in eosinophil-rich mucin without any evidence of tissue invasion. So the pathologist should assess the mucin not the polyp.

An allergic mucin contains necrotic inflammatory cells, eosinophils and Charcot-Leyden crystals (byproduct of Eosinophilic degranulation).

​

Treatment: It includes surgery, steroids, immunotherapy and antifungal agents.

Surgery: Surgical removal of all allergic mucin.

� Steroids: If it is difficult to remove allergic mucin completely, then remission is achieved with systemic �steroids. In cases of recurrence, repeated surgical removal of mucin combined with perioperative steroids (prednisone 60 mg for several days and tapered off over 2 to 4 weeks) is beneficial.

​

Immunotherapy: It contains fungal agents, started within 4–8 weeks of surgery, and prevents recurrence.

​

Oral antifungal agents: Their role is controversial. A long course of oral itraconazole (400 mg daily for 1 month and tapered over 3 months) needs regular monitoring of liver functions. It has shown good results.

Allergic Fungal Sinusitis