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Fungal Sinusitis: types, causes, symptoms, risk factors, treatment

Definition: Fungal Sinusitis describes different conditions when fungi are involved in the causes or symptoms of sinus or nasal inflammations.

Classification (Types):

Noninvasive: (extra mucosal)
I. Fungal ball.
II. Allergic fungal sinusitis.

Invasive: (submucosal invasion)
III. Fulminant type [acute form]
IV. Indolent type [chronic form]
fungal-sinusitis

I. Fungal ball

It occurs in hyperimmune (atopic) individuals. Maxillary sinus is the most common followed by sphenoid sinus. Mainly caused by aspergillus.

Symptoms: Nasal discharge and posterior nasal drip.
Signs: Nasal discharge from the affected sinus seen endoscopically.

Investigations
C.T.: Unilateral opacity affecting maxillary and/or sphenoid sinus with metallic dense shadow at center.
Treatment:
Surgical: Transnasal endoscopic surgery: Middle meatal antrostomy and/or sphenoidotomy with removal of the fungal ball and profuse irrigation.
Recurrence: uncommon.

II. Allergic fungal sinusitis

Usually occurs in immune competent individuals. Origin is mostly from the ethmoids and maxillary sinuses.
Etiology: caused by allergy to fungi mainly Aspergillus and Alternaria.

Symptoms:
  • Nasal obstruction: Usually unilateral, of gradual onset and progressive course.
  • Anterior nasal discharge: usually unilateral, thick, tenacious and offensive.
  • Proptosis: unilateral and only in advanced cases especially in children.
Signs:
  • Unilateral, multiple, soft, gray and glistening nasal polyps, arising mainly from the middle meatus.
  • Unilateral thick, yellow and mucoid nasal discharge and/or fungal mud.
Investigations:
  1. Endoscopy: polyps, mud and mucin mainly at the middle meatus.
  2. CT: usually unilateral opacity affecting the nose and/or one or more paranasal sinuses associated with characteristic calcifications and mottling in soft tissue window images.
  3. Biopsy: polyps with eosinophils and fungus hyphae.
Treatment:
a. Medical:
  • Nasal Saline wash
  • Corticosteroids: systemic and local
  • Immunotherapy.
b. Surgical
Transnasal endoscopic pan sinus surgery aiming at
  •  Removal of all the polyps, mucin and fungal debris.
  • Offering proper aeration and drainage of the affected sinuses
Recurrence: common.

III. Invasive fulminant type


Occurs in immune compromised individual e.g. diabetes, uremia, AIDS, patients under cytotoxic or steroid therapy.
Organism: Mucormycosis causing intravascular thrombosis and gangrene.
Progress: acute onset, rapidly progressive course, and lethal in short time in uncontrolled cases.

Symptoms:
  • Early: Pain, headache and fever.
  • Late: unilateral nasal obstruction, ocular and/or cranial symptoms.
Signs:
  • Black intranasal structures including inferior and/or middle turbinate, later on the nasal septum, gangrenous skin of the cheek, and gangrene and perforation of the palate.
  • Offensive nasal discharge
  • Ocular extension may lead to proptosis, ophthalmoplegia and blindness.
  • Cranial extension may lead to cranial nerve palsies, coma and lastly death.
Investigations:
1. CT:
  • Early: unilateral opacity of the turbinate/s and/or ethmoid sinus.
  • Late: unilateral extensive opacity involving most of the sinuses and extending beyond the sinonasal framework to the orbit and/or cranial cavity.
2. Biopsy: necrotic gangrenous tissue and intramucosal fungal hyphae.

Treatment:
  1. Surgical debridement of all the gangrenous tissue.
  2. Systemic antifungal drugs (Amphotericin B). The patient should be hospitalized and the liver and kidney functions monitored daily.
  3. Control of the original disease causing the immune compromised status.
Prognosis: very bad.

IV. Indolent fungal sinusitis


Occurs in immune competent individuals.
Organism: Aspergillus.
Progress: insidious onset slowly progressive course, lethal after long time.

Symptoms: 
  • Unilateral obstruction, discharge, ocular and/or cranial symptoms in advanced cases.
Signs:
  • Unilateral reddish nasal mass. Ocular and cranial affection occur late
Investigations:
1. CT: unilateral extensive opacity involving most of the sinuses and extending beyond the sinonasal framework to the orbit and cranial cavity in late cases.
2. Biopsy: Granuloma and fungal hyphae.

Treatment: 
Surgical debridement, with antifungal drugs: systemic intravenous voriconazole.
Prognosis: bad.


Key points 

  • Fungal rhinosinusitis should be considered in all resistant cases of chronic rhinosinusitis. 
  • Mucosal Invasion is the main stay in classification. 
  • Immunity should be considered whether immunocompetent, immune compromised or hyper immune (atopic). 
  • Management differs dramatically according to type of infection.

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