Fungal rhnosinusitis

1. FUNGAL RHINOSINOSITIS

2. INTRODUCTION
FUNGAL DISEASE OF THE
NOSE & PARANASAL
SINUSES REPRESENTS AN
INVASIVE DEADLY DISEASE

3. EXTENSIVE SURGICAL
DEBRIDMENT
SYSTEMIC ANTIFUNGAL
TOPICAL ANTIFUNGAL
agents

4. Classification of fungal
rhinosinusitis
• Acute fungal rhinosinusitis
• Chronic fungal rhinosinusitis
• Fungal ball
• Saprophytic fungal colonization
ALLERGIC FUNGAL RHINOSINUSITIS

5. INTRODUCTION
PATHOPHYSIOLOGY
CAUSES
CLINICAL PRESENTATION
DIAGNOSIS
TREATMENT
ALLERGIC FUNGAL RHINOSINUSITIS

6. INTRODUCTIONS
• Non-invasive fungal disease
• Most common type of fungal sinusitis
• Affect adolescent or young adult
• It may become invasive &
lifethreatining disease
• Affected patient need special care

7. • Described 1st by McCARTHY&
PEPYS at 1971
• In 1976 SAFIRSTEIN reported
same finding
• 1980s Disease was widely
accepted as a benign fungal
process
• 1989 “ ALLERGIC FUNGAL
SINUSITIS “>>>> ROBSON

8. Epidemiology of AFRS
• Common among adolescent & young adults
• Common in atopic individuals
70% Allergic rhinitis
90% high serum IgE
50% of patients having asthma
• Very common type of FRS
• 5-10% of patients with CRS
• Geographic distribution may play a role
• It was found common in area with
high temp & high humidity

9. Causative organism
• Aspergillus species
Flavus
• Dematiaceous fungi
Curvularia
Bipolaris
Exserohilum
Alternaria

10. Pathophysiology
• Remain unclear
• Similar to that of ABPA
• Several theories have been offered
• MANNING & COLLEAGUS theory
• AFRS vs ABPA
• Many factors play a role in disease
developments

11. Fungal
inhalation Stimulation
Of immune
system
EOSINOPHILS
PRODUCTION
Anatomical
deformities
Stasis
Decrease
ventilation
Fungal
Proliferation
Agx. EXPOSURE
Atopic
Host
Allergic
Mucin
production
AFRS

12. Clinical features
Patient features
• Adolescent or young adult
• Immunocomptent
• Atopic individual
• Male to female is almost equal
DRAMATIC PRESENTATION

13. Presenting
symptoms
Slowly progressive
predominantly
unilateral symptoms

15. Clinical presentation
• Nasal obstruction / congestion
• Post nasal discharge
• Purulent rhinorrhea
• Headache or facial fulness
• Proptosis & telecanthous
• Blowing semi-solid material from nose
• Multiple sinus surgery

16. cont
• Facial dysmorphia
• Refractory or recurring sinus
symptoms
• Visual loss
• Anosmia
• Nasal polyposis
• SEMISOLID NASAL DISCHARGE

17. • UNILATERAL MULTIPLE COMPLETE SINUS OPACIFICATION
• EXPANSION OF THE INVOLVED SINUSE
• DISPLACEMENT OF ADJACENT ANATOMIC COMPARTMENT
• HYPERATTENUATION ( CALCIFICATION)
• INTRAORBITAL EXTENSION
• INTRACRANIAL EPIDURAL EXTENSION
• MUCOCELE FORMATION
 HETROGENCITY OF SIGNAL WITHIN THE INVOLVED SINUS
 EROSION OF THE BONE BORDERNIG THE INVOLVED SINUS
CT SCAN FINDING IN AFRS

18. EXTRASINUS EXTENSION
OF AFRS IS CAUSED BY BONE
RESORPTION DUE TO
PRESSURE EFFECT NOT DUE
TO FUNGAL INVASION
PROCESS

19. Epidural extension

20. Sinus opacification, hyper attenuation
Bilateral sinus involvement
Ballooning appearance

21. MRI FINDING
LOW SIGNALS ON T1&T2 WI IN CENTRAL
AREAS
WITH PERIPHRAL HIGH SIGNALS DUE TO
INFLAMMED MUCOSA

22. WHAT ARE THE INCIDENCE OF THE
FOLLOWING IN AFRS
PROPTOSIS
INTRAORBITAL EXTENSION
SKULL BASE INVASION

23. DIFFERENTIAL DDX
 INVASIVE FUNGAL RHINOSINUSITIS
 INVERTED PAPILLOMA
 SAMTER’S SYNDROME
 ANGIOFIBROMA
LYMPHOMA
SARCOMA
AFRS
SCCA

24. Diagnostic criteria
Clinical aspect
Radiological finding
Immunological study
Histological finding

25. DIAGNOSTIC CRITERIA
• Type 1 hypersensitivity reaction
• Nasal polyposis
• Characteristic CT SCAN finding
• Positive fungal hyphae
Presence of ALLERGIC MUCIN OR
ESINOPHILIC MUCIN with out
evidence of mucosal invasion

26. Diagnostic criteria
symptoms Nasal obstruction
Anterior &/or PND
Decrease sense of smell
Facial pressure or fullness
Obj.
finding Presence of allergic mucin , FH ,EOSINO
Evidence of fungal specific IgE
No histological evidence of fungal
invasion
R
A
D
i
O
Logical finding
Ct scan of PNS showed
Characteristic finding of AFRS
Bone erosion, sinus expansion , ext. of disease to
adjacent anatomical areas

27. Other diagnostic measures
Possible ,but not required
Fungal culture
Total serum IgE
Imaging by more than one technique

31. Allergic mucin
• Peanut –buttery tan to dark –
brown thick tenacious material
• Onion-skin laminations of
necrotic & degranulated
esinophilis in background of
mucin

33. Histopathological finding
• Allergic mucin
• Charcot-leyden crystals
• Fungal hyphae
• No evidence of :
Mucosal invasion
Mucosal necrosis
Granuloma & giant cells

34. Hematological finding
• Increase IGE level
• Increase fungal specific IGE & IGg
level
• Peripheral blood esinophilia often
present

35. Treatment

36. Protocol for
preoperative
treatment

37. • Biopsy
• Oral steroids
• Topical steroids
• Anti-allergic meds
• Nasal irrigation
• CTSCAN ONE DAY BEFORE SURGEY
• SURGERY ( FESS)
NEW APPROACH FOR AFRS IN ACH

38. Goals of surgical treatment
Eradicate all allergic mucin
Providing permanent drainage
Providing ventilation route

39. Rate of recurrence is high
despite of complete
surgery,
Medical therapy should be
used as adjunctive to
surgery

40. Treatment of AFRS consist of
Surgical treatment
Corticosteriods therapy
Anti-allergic therapy
Anti-inflammatory drugs
Topical anti-fungal therapy
Nasal irrigations

41. New treatment for AFRS
 IMMUNOTHERAPY
 TOPICAL ANTIFUNGAL NASAL
IRRIGATION
 IMMUNOMODULATION

42. POSTOPERATIVE TREATMENT
• ORAL STEROIDS
• TOPICAL STEROIDS
• REGULAR NASAL IRRIGATION
• ANTI-ALLERGY
• REGULAR FOLLOW UP

43. AFRS IN CHILDREN
NEED SPECAIL CARE
MORE AGGRESSIVE
BONE EROSION IS SEVER
INTRAORBITAL EXTENSION
IS HIGH
INTRACRANAIL EXTENSION
IS MORE AGGRESSIVE