Fungal sinusitis is a clinical entity characterized by inflammation of sinus mucosa due to fungal infection. Seen in immunocompetent/immunocompromised hosts.
CAUSATIVE AGENTS Aspergillus Mucormycosis Paecilomyces Candida Penicillium species
CAUSATIVE FACTORS Diabetics and immunocompromised patients. Patients with chronic renal failure. Prolonged systemic steroids. Chemotherapy. Prolonged use of steroid nasal spray.
Classification Non invasive fungal sinusitis o Allergic fungal rhinosinusitis(AFRS). o Mycetoma. Invasive fungal sinusitis. o Acute invasive fungal sinusitis. o Chronic invasive sinusitis.
CHRONIC INVASIVE FUNGALSINUSITIS Slowly progressive fungal infection with a low- grade invasive process. Diabetic patients. Presents with symptoms of long standing sinusitis. Persistent and recurrent. Orbital apex syndrome,occular immobility. Bipolaris and aspergillus.
Treatment Surgical treatment-mandatory. Antifungal therapy. o Amphotericin B(2-3g) o Replaced by itroconazole/ketoconazole. Long term follow up care is required.
ACUTE FULMINANT FUNGALSINUSITIS Most lethal form of fungal sinusitis. Seen in immunocompromised ,diabetics and advanced AIDS. Symptoms include fever, facial pain or numbness, nasal congestion, serosanguineous nasal discharge, and epistaxis Intraorbital, intracranial, and maxillofacial extension is common.
Characterised by a painless, necrotic nasal septal ulcer ,sinusitis, and rapid orbital and intracranial spread leading to death.
Treatment Emergency surgery required. Radical debridement of necrotic tissue. Antifungal treatment. Long term follow up care required. Has a poor prognosis.
ComplicationsOnce untreatedcavernous sinusthrombosis andinvasion of CNSdevelops.
FUNGAL BALL Implantation of fungus into sinus cavity. Usually unilateral. Maxillary sinus commonly involved. Seen in immunocompetent. Commonest cause-Aspergillus species.
TREATMENT Recommended treatment is surgical. No antifungal treatment is necessary.
ALLERGIC FUNGAL RHINOSINUSITIS
Most common form of fungal sinusitis. Recognised as IgE mediated response to dematiaceous fungi. Aspergillus spp, Bipolaris Curvularia Alternaria
Criteria for diagnosis1. Type 1 hypersensitivity.2. Nasal polyposis.3. Characteristic CT scan appearance.4. Thick eosinophilic mucin.
Presentation Atopic Present with signs and symptoms of nasal airway obstruction, chronic sinusitis that includes nasal congestion, purulent rhinorrhea, postnasal drainage.
Coronal CT scan showing typical unilateralappearance of allergic fungal sinusitis withhyperintense areas and inhomogeneity ofthe sinus opacification; the hyperintenseareas appear whitish in the center of theallergic mucin.
A 15-year-old boy with allergic fungalsinusitis causing right proptosis,telecanthus, and malar flattening; theposition of his eyes is asymmetrical, and hisnasal ala on the right is pushed inferiorlycompared to the left
ALLERGIC MUCIN Reliable indicator. Appears thick,tenacious,peanut butter like brown green mucus containing eosinophils,charcot laden crystals and hyphae.
IgE levels Total IgE values generally are elevated in AFS(90%) Total IgE level traditionally has been used to monitor the clinical activity of allergic bronchopulmonary fungal disease. IgE levels have been proposed as a useful indicator of AFS clinical activity.
TREATMENT Surgical debridement of mucin and polyps. Administration of systemic steroids. Topical nasal steroid are helpful postoperatively. Aggressive nasal salt-water washes are recommended.
Coronal MRI showingexpansion of the sinuseswith allergic mucin andpolypoid disease; thehypointense black areas inthe nasal cavities are theactual fungal elements anddebris. The density abovethe right eye is themucocele. The fungalelements and allergicmucin in allergic fungalsinusitis always lookhypointense on MRIscanning and can bemistaken for absence ofdisease.
COMPLICATIONS OF FUNGALSINUSITIS Orbital cellulitis. Orbital abscess. Intracranial invasion causing meningitis. Cavernous sinus invasion.