An International Journal of Otorhinolaryngology Clinics

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2009 | September-December | Volume 1 | Issue 1

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REVIEW ARTICLE

Shiv Sekhar Chatterjee, Arunaloke Chakrabarti

Epidemiology and Medical Mycology of Fungal Rhinosinusitis

[Year:2009] [Month:September-December] [Volume:1] [Number:1] [Pages:14] [Pages No:1 - 14]

Keywords: Fungal sinusitis,epidemiology,Aspergillus,allergy,fungi

   DOI: 10.5005/jp-journals-10003-1001  |  Open Access |  How to cite  | 

Abstract

Fungal rhinosinusitis (FRS) refers to a spectrum of disease ranging from benign colonization of the nose and sinuses by pathogenic fungi to acute invasive and fatal inflammation extending to the orbit and brain. FRS is classified into two categories: invasive and noninvasive. Invasive FRS may again be subcategorized into acute invasive (fulminant) FRS, granulomatous invasive FRS, and chronic invasive FRS; while noninvasive FRS is subcategorized into localized fungal colonization, sinus fungal ball and eosinophil related FRS (including allergic fungal rhinosinusitis, eosinophilic fungal rhinosinusitis). This classification is not without controversies, and intermediate and semi-invasive forms may also exist in particular patients. Acute invasive FRS is an increasingly common disease worldwide among the immunocompromised patients and caused most frequently by Rhizopus oryzae, and Aspergillus spp. Granulomatous invasive FRS has mostly been reported from Sudan, India, and Pakistan and is characterized by noncaseating granuloma formation, vascular proliferation, vasculitis, perivascular fibrosis, sparse hyphae in tissue, and isolation of A. flavus from sinus contents. Chronic invasive FRS is an emerging entity occurring commonly in diabetics and patients on corticosteroid therapy, and is characterized by dense accumulation of hyphae, occasional presence of vascular invasion, sparse inflammatory reaction, involvement of local structures, and isolation of A. fumigatus. While localized fungal colonization describes the most benign of all fungal sinusitis in the superficial nasal crusts, sinus fungal ball is a dense mycetoma like aggregate of fungal hyphae in diseased sinuses. Common in southern Europe, especially France, majority of them are sterile on culture while 30-50% may yield Aspergillus spp. The definitions and pathogenesis of the group of syndromes in eosinophil related FRS (AFRS, EFRS) are contentious and a matter of intense research among otolaryngologists, pathologists, immunologists and microbiologists. While dematiaceous fungi are the foremost initiators of these syndromes in the west, Aspergillus flavus is the predominant pathogen in India and the Middle-East.

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REVIEW ARTICLE

Radiologic Appearances in Fungal Rhinosinusitis

[Year:2009] [Month:September-December] [Volume:1] [Number:1] [Pages:10] [Pages No:15 - 24]

Keywords: Imaging,computed tomography,paranasal sinuses,diagnosis

   DOI: 10.5005/jp-journals-10003-1002  |  Open Access |  How to cite  | 

Abstract

Radiological diagnosis forms an important tool in the armamentarium to diagnose and classify fungal rhinosinusitis. However, many times, the appearances may be deceptive; while on one hand in Allergic Fungal Rhinosinusitis the appearance is classical and considered one of the clinchers in the diagnosis of the condition, in invasive fungal rhinosinusitis (especially in the early phases), the appearances may range from a nonspecific sinusitis to even a ‘apparently normal’ scan! CT scan as well as MRI may at times complement each other, in order to aid the clinician arrive at a diagnosis. Nevertheless, despite the best radiologic modalities, a clinicoradiological correlation is a must to accurately diagnose this often deceptive condition called fungal rhinosinusitis.

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REVIEW ARTICLE

Mohan Kameswaran, S Raghunandhan

Saprophytic Mycotic Infections of the Nose and Paranasal Sinuses

[Year:2009] [Month:September-December] [Volume:1] [Number:1] [Pages:8] [Pages No:25 - 32]

Keywords: Saprophytes,mycosis,mucor,immunocompromised state,allergic fungal sinusitis,invasive fungal sinusitis,antifungal therapy

   DOI: 10.5005/jp-journals-10003-1003  |  Open Access |  How to cite  | 

Abstract

The kingdom of fungi is ubiquitous and omnipresent, having prevailed over the tides of time, over numerous decades by adapting to various methods of survival in the susceptible host including humans. Saprophytic fungi derive nutrition from dead and decaying organic matter, with the capacity to flare up in virulence, provided the right opportunity especially when the host immunity is compromised (as in prolonged steroid therapy, diabetes, HIV infection, tissue transplant recipients) or if there is a breech in a vital barrier permitting deeper tissue penetration (postsurgical or post-traumatic). Hence, knowledge about the saprophytic fungal elements dwelling within the nose and paranasal sinuses is paramount for Otolaryngologists worldwide, in order to accurately diagnose and effeciently manage such intriguing cases. This article provides a broad overview of the various opportunistic fungi in rhinology, and highlights the principles of diagnosis and protocols in management.

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REVIEW ARTICLE

Fungus Balls of the Paranasal Sinuses

[Year:2009] [Month:September-December] [Volume:1] [Number:1] [Pages:4] [Pages No:33 - 36]

Keywords: Aspergilloma,fungus ball,paranasal sinuses

   DOI: 10.5005/jp-journals-10003-1004  |  Open Access |  How to cite  | 

Abstract

Fungal balls are extramucosal collections of fungal elements, usually localized to a single sinus cavity, commonly the maxillary sinus. They are usually of the noninvasive variety, and commonly seen in immunocompetent hosts. Occasionally a waning of the immunity can cause them to turn invasive. Much controversy exists regarding its management – medical as well as surgical. Endonasal evacuation of the involved sinus is usually all that is required to manage this condition.

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REVIEW ARTICLE

Allergic Fungal Rhinosinusitis

[Year:2009] [Month:September-December] [Volume:1] [Number:1] [Pages:8] [Pages No:37 - 44]

Keywords: Nasal polyps,hypersensitivity,sinusitis,Aspergillosis,steroids,itraconazole

   DOI: 10.5005/jp-journals-10003-1005  |  Open Access |  How to cite  | 

Abstract

Allergic fungal rhinosinusitis (AFRS) is one of the more commonly encountered forms of noninvasive fungal rhinosinusitis, seen in immunecompetent individuals. It is caused by a Gell and Coombs Type I, IgE mediated (and possibly Type III) hypersensitivity reaction to an extramucosal fungal antigen. It bears striking similarities to Allergic Broncho Pulmonary Aspergillosis (ABPA), in terms of pathogenesis as well as treatment. It commonly presents as nasal polyposis. Most current treatment protocols for this condition are based on a combined medical and surgical approach. In this article we have recapitulated the history, epidemiology, etiology, clinical features, diagnostic investigations and treatment protocols for this disease.

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REVIEW ARTICLE

Kailashnath Sant

Invasive Fungal Sinusitis: An Overview

[Year:2009] [Month:September-December] [Volume:1] [Number:1] [Pages:4] [Pages No:45 - 48]

Keywords: Fungal sinusitis noninvasive

   DOI: 10.5005/jp-journals-10003-1006  |  Open Access |  How to cite  | 

Abstract

Currently two main categories of fungal sinusitis are described; invasive and noninvasive. The invasive type can be; 1. Acute, fulminant, 2. Chronic, indolent, and 3. Granulomatous type. The noninvasive types are more common of which Allergic fungal sinusitis is commonly present in almost all extensive polyposis cases in India. The other noninvasive type is mycetoma or fungal ball, which carries the best prognosis if treated surgically well. The acute invasive fugal infection of sinuses by mucormycosis is an aggressive opportunistic infection caused by phycomycetes, first described in 1885 by Paltauf. The genera most commonly causing mucormycosis are Mucor or Rhizopus. Sinus and nasal infection by mucor causes orbitocerebral spread. Other organs involved are the lungs, GI tract and skin. Rhinorbito-cerebral mucormycosis has a mortality rate as high as 50%, since they occur in immunocompromised state like uncontrolled diabetes, metabolic acidosis, chronic renal failure, AIDS, leukemia, etc.

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REVIEW ARTICLE

Gopika Kalsotra

Rhinocerebral Mycosis: Combined Modality Protocol

[Year:2009] [Month:September-December] [Volume:1] [Number:1] [Pages:6] [Pages No:49 - 54]

Keywords: Rhinocerebral mycosis,itraconazole,Amphotericin B,mucormycoses,invasive

   DOI: 10.5005/jp-journals-10003-1007  |  Open Access |  How to cite  | 

Abstract

Rhinocerebral mycosis is an invasive fungal infection which occurs primarily in the paranasal sinuses and progresses to involve the brain and/or the orbit. It is commonly seen in immunocompromised individuals and can be most effectively treated if diagnosed early, when it is limited to the nasal cavity and the paranasal sinuses. Even though it is acceptable that surgical debridement in combination with antifungal therapy can lead to high rate of cure, the surgical approach for intracranial extension is still a subject of debate. Twenty-four cases of rhinocerebral mycosis managed at our institute are discussed, regarding presenting complaints and management.

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REVIEW ARTICLE

Anamika Rathore, Nishit J Shah

Intracranial Extension of Fungal Sinusitis

[Year:2009] [Month:September-December] [Volume:1] [Number:1] [Pages:8] [Pages No:55 - 62]

Keywords: Intracranial extension,fungal sinusitis

   DOI: 10.5005/jp-journals-10003-1008  |  Open Access |  How to cite  | 

Abstract

Intracranial extension is the most dreaded complication of fungal sinusitis with high mortality rates. Fungal sinusitis is notorious for insidious and rapid intracranial spread. Therefore the most appropriate approach lies in timely diagnosis and early intervention.

With various diagnostic modalities available; like CT scan, MRI, fungal stains, cultures and nasal endoscopy, the diagnosis has become much simpler, nevertheless, a high degree of clinical suspicion is a must.

The treatment outcomes have now improved a lot, with the advancement in medical and surgical technology. The new antifungal agents and other drugs have immensely contributed to better results by minimizing the toxic side effects of the traditional drugs and showing better efficacy. The surgical approach, with the advent of endoscopes has led to successful outcomes.

Despite this, in about 50% of the cases, since the host is immunocompromised, the prognosis is guarded and mortality rates of approximately 85 to 100% are noted.

So, it is very important to treat intracranial extension of fungal sinusitis as a medical and surgical emergency.

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REVIEW ARTICLE

Medical Therapy for Fungal Rhinosinusitis

[Year:2009] [Month:September-December] [Volume:1] [Number:1] [Pages:6] [Pages No:63 - 68]

Keywords: Amphotericin B,Itraconazole,Voriconazole,Azole,steroids,antifungal

   DOI: 10.5005/jp-journals-10003-1009  |  Open Access |  How to cite  | 

Abstract

Medical therapy forms an important modality in the management of fungal rhinosinusitis. This essentially comprises of topical as well as systemic antifungals, steroids or both, depending upon the nature of the disease. The drugs may need to be started preoperatively in some conditions, but it is essentially the postoperative management which is vital to prevent recurrences, and may sometimes continue for months. Discussed here are the various forms of fungal rhinosinusitis and their proposed regimens.

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REVIEW ARTICLE

Surgical Management of Fungal Rhinosinusitis

[Year:2009] [Month:September-December] [Volume:1] [Number:1] [Pages:7] [Pages No:69 - 75]

Keywords: Fungal rhinosinusitis,fungus ball,invasive,endoscopic surgical procedures

   DOI: 10.5005/jp-journals-10003-1010  |  Open Access |  How to cite  | 

Abstract

Fungal rhinosinusitis is on the rise. Most current treatment protocols for fungal rhinosinusitis include surgery combined with medical therapy. Endoscopic sinus surgery has revolutionized the management of this disease limiting the use of the open surgical approaches to very extensive cases with orbital, soft tissue or intracranial involvement by invasive fungal rhinosinusitis. A regular and thorough follow-up is mandatory in all cases to check for recurrences. This article discusses the various forms of fungal rhinosinusitis and their surgical management.

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