The document provides an overview of fungal sinusitis. It discusses the different types including invasive and non-invasive forms. Superficial sinonasal mycosis and fungal balls are described as non-invasive types. Chronic and acute invasive fungal sinusitis are outlined as more serious conditions affecting immunocompromised individuals. Key signs, symptoms, diagnostic techniques and treatment approaches are summarized for each type. A variety of fungi that can cause infection are also named.
2. Intro
• Rare - is it?
• Increased incidence in last 2 decades
• Presence of Fungi in 100% normal and 96% chronic RS
• Recent technology in serology, histology MYCOLOGY &
radiology contributed to detection
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
3. Risks
• Diabetes mellitus
• Increased use of broad spectrum antibiotics
• Topical nasal spray – inadvertent and indicative use
• Acquired immunodeficiency states- viral,
immunosuppressive drug intake (post-organ
transplantation), chronic steroid users
• Defective immune response states- post-radiotheray and
chemotherapy
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
5. Peak into Mycology
• Fungi grows well in
• Humid and wet environment
• High osmotic ( high glucose)
• Acidic environment
• Mucor, Rhizopus, Aspergillus sp
• Smears and culture
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
6. Aspergillus
• Aspergillus
• Longitudinally-
centrifugally in cultures,
tubular hyphae
• 45 degree Y- shaped
hyphae
• Does not require light
• Needs a host for metal
ions, glucose, nitrogen,
sulphur, calcuim, ZINC
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
7. Mucor
• Mucor
• Rhizopus, Mucor,
Absidia
• Hyphae vary in width,
branch off at 90 degree
• Propensity for vascular
invasion high ( higher
incidence in Diabetic
ketoacidosis)
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
13. Superficial sinonasal mycosis
• NON-INVASIVE
• Mc in post surgical, immunosuppressed and such
• Aspergillus, Candida sp
• Part of flora of mucous membrane
• Arise when local systemic factors decrease resistance of
the patient
• Such as local mucous membrane continuity disruption-
ulcers, nasal sprays, radiation
• General risk factors
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
16. • Smears to be taken – not miss out malignancy
• Mixed cultures
• Biopsy
• DD- Malignancy, TB
• Careful removal of crusts and debris by endoscopic
visualization
• Local irrigation with Clotrimazole / naftifine
• Milder cases Ketoconazole is valuable in Oral therapy
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
17. • In chronic Aspergillus or Candida, in extensive invasion of
mucous membrane or when specific complications are
expected , Ampho –B, with or without Flucytosine IV
• Both A.fumigatus and Candida sp can become inhaled
allergens and trigger or sustain specific rhinopathies and
asthma
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
18. Fungal ball
• NON-INVASIVE
• An overgrowth of fungal elements in the sinuses
• Most commonly molds such as Aspergillus are
responsible.
• The most commonly involved sinuses –
• maxillary and the sphenoid sinuses, where the fungus finds
favorable conditions such as warmth and humidity for growth.
• Sometimes, bacteria can cause super-added infection in the sinus
affected by the fungus ball.
• Typically, only a single sinus is involved, and the disease
has a classic appearance on CT or MRI scans.
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
22. • Surgical removal of the fungus ball through endoscopic
sinus surgery.
• Characteristic ‘peanut-butter’- like appearance of the
fungal ball
• Most have excellent results from surgery, and may not
require any further treatment
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23. Allergic Fungal RS- NON-INVASIVE
• Immunocompetent patients
• Allergy to fungi
• The causative fungi resides in the mucin and provides
continued allergic reaction
• Similar ABPA
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
24. • Allergic mucin
• Type 1 hypersensitivity
• <30 years, no gender predominance
• May associate wit polyps
• Mucin – hyphae
• Culture necessary
• RAST, total IgE, antigen specific IgE or IgG
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25. Diagnostic criteria (Bent & Kuhn)
• Major
• Type I hypersensitivity confirmed by history, skin tests or serology
• Nasal polyposis
• Characteristic CT scan signs
• Positive Fungal stain or culture
•
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
26. • Minor
• Asthma
• Eosiophilic mucus with fungal elements and no tissue invasion
• Unilateral predominance
• Radiographic bone erosion
• Charcot- Leyden crystals (Lysophospholipase)
• Peripheral Eosinophilia
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27. Diagnostic criteria
• Kupferberg – Endoscopic (for the purpose of post
operative management)
• Stage 0- no mucosal oedema or allergic mucin
• Stage 1- Mucosal oedema with or without allergic mucin
• Stage 2- polypoid oedema with or without allergic mucin
• Stage 3- sinus polyps with fungal debris or allergic mucin
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31. Treatment
• Removal of all mucin
• Recurrence is common
• Prednisone in oral – during entire treatment regimen (
start before surgery and continue after surgery and taper
and stop as per response)
• No use for systemic and topical anti-fungals ( Mabry et al)
• Immunotherapy with fungal antigens and positive non-
fungal antigens – reduces necessity for systemic &/ local
steroids and chances of recurrence. (Mabry et al)
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33. Chronic invasive (indolent) fungal RS
• Two variants based on presence of granulomas within
tissue
• Granulomatous
• Non-granulomatous
• Healthy individuals with previous history Chronic RS
• An asymptomatic period occurs only when orbit or skull
base are involved
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
34. Chronic Fungal RS
• Slower destructive process
• Rarely causes vascular invasion, sparse inflammatory
reaction and limited involvement of surrounding
structures.
• Common in HIV, Diabetes mellitus and long term use of
steroid
• Most commonly affects Ethmoid and Sphenoid
• The typical time course of the disease is over 3 months.
• Tissue cultures show fungus in over half the patients, and
Aspergillus fumigatus is the most commonly grown
fungus.
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
35. Granulomatous Chronic Fungal RS
• Present with an enlarging mass in the cheek, orbit, nose,
and sinuses.
• Microscopically, it is characterized by formation of
granulomas, and this differentiates it.
• Aspergillus flavus is usually the causative organism.
• Treatment may involve surgery in combination with
antifungal agents.
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37. • Treatment
• Surgery in combination with medical therapy
• Anti-fungal drugs and
• Measures to restore the patient’s immune system
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38. Acute (fulminant) fungal RS
• Most dangerous and life-threatening form of fungal sinusitis.
• Very rare
• usually only affects severely immunocompromised patients
• leukemia, aplastic anemia, uncontrolled diabetes mellitus, and
hemochromatosis.
• anti-cancer chemotherapy or organ/ bone-marrow transplantation are
especially susceptible.
• Aspergillus or Mucor, Rhizopus are the most frequent causative
agents.
• Has an aggressive course, with fungus rapidly growing through
sinus tissue and bone to extend into the surrounding areas of
the brain and eye.
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39. • Endoscopically areas of dead tissue and eschar are
noted.
• Microscopic examination shows invasion of blood vessels
by the fungus, leading to necrosis.
• Treatment - aggressive surgical and medical therapy.
• Repeated surgery may be necessary to remove all dead
tissue.
• Anti-fungal drugs and restoring the immune status of the
patient are key to improving survival, as this disease is
frequently fatal
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40. Fungal rhinosinusitis with orbital and cranial invasion (yellow
arrows) References: Dept. of Radiology, Hospital Clinic
Barcelona - Barcelona/ES
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41. Assessment of immune status
• Complete blood count with differential
• Blood chemistry
• Liver function enzymes
• Autoimmune enzymes
• Anergy panel for cellular and humoral immunity
• HIV testing
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42. Management
• Investigations and Treatment with Follow-up
• Clinical
• Laboratory
• MYCOLOGY LAB
• Radiological
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
43. • Before starting treatment
• Usg pelvis with abdomen
• Renal function tests with all electrolytes
• Liver unction tests
• PT, activated PTT
• BT, CT
• Blood counts and ESR
• Chest X ray, ECG
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44. Monitor
• Serum / blood glucose, urine glucose and urine ketones
everyday
• Blood urea, creatinine, Na and k on alternate days
• Mg and Ca with serum bilirubin and Albumin every 3rd day
• ECG every 3rd day
• Input and output charts
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45. Glycemic control
• Diabetologist
• Insulin analogues best
• With sliding scale / fixed dose (former better during active
management)
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47. Surgery
• Endoscopic removal
• Aggressive in invasive lesions
• Dictum- remove till fresh bleeding points
• Saline flush and remove technique for fungal balls
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
48. Amphotericin-B
• THE drug
• Various forms
• Regimen to be completed for success in therapy
• No difference in liposomal and convential except finish the
course earlier
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
49. MOA
• Amphotericin B binds with ergosterol, a component of
fungal cell membranes, forming pores that cause rapid
leakage of monovalent ions (K+, Na+, H+and Cl− ) and
subsequent fungal cell death.
• This is amphotericin B's primary effect as an antifungal
agent.
• It has been found that the amphotericin B/ergosterol
bimolecular complex that maintains these pores is
stabilized by Van der Waals interactions
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
50. Bioavalability 100% (IV)
Metabolism kidney
Biological half-life initial phase : 24 hours,
second phase : approx. 15 days
Excretion 40% found in urine after single
cumulated over several days
biliar excretion also important
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51. • Very often, it causes a serious reaction soon after infusion
(within 1 to 3 hours)
• high fever, shakingchills,
• hypotension,
• anorexia,
• nausea, vomiting, headache, dyspnea and tachypnea, drowsiness,
and generalized weakness.
• The violent chills and fevers have been nicknamed "shake and
bake"
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
52. • This reaction sometimes subsides with later applications of the
drug, and may be due to histamine liberation.
• An increase in prostaglandin synthesis may also play a role.
• This nearly universal febrile response necessitates a critical
(and diagnostically difficult) professional determination as to
whether the onset of high fever is a novel symptom of a fast-
progressing disease, or merely the effect of the drug.
• To decrease the likelihood and severity of the symptoms, initial
doses should be low, and increased slowly.
• Paracetamol, pethidine, diphenhydramine
and hydrocortisone have all been used to treat or prevent the
syndrome, but the prophylactic use of these drugs is often
limited by the patient's condition.
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
53. • S/E
• Renal failure
• Hypokalemia
• Hypomagnesimia
• Heapatotoxicity and fulminant liver failure
• Anemia and blood dyscrasias
• Severe cardiac arrhythmias (VF)
• Cardiac failure
• Sever skin reactions
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
54. Amphotericin B
• During every dose
• One pint Normal saline before infusion and one pint
Normal saline after infusion
• Dose 0.25-0.5mg/kg/day body weight
• Start with test dose MUST DAY 1
• 50mg in 50 ml DEXTROSE containing solution and use 1 ml in 100
ml d5 over 30 minutes
• Discard remaining (though cost effective measure is use it for nasal
douching)
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55. • DAY 2
• 50mg in 50 ml D5 , infuse 5ml in 100 ml D5 over 1 hour
• DAY 3
• 50mg in 50ml D5, infuse 10 ml in 300 ml D5 over 1 hour
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
56. • DAY 4 - 25ml
• DAY 5 - 50ml
• DAY 6 – 50ml
• 50ml is 50 mg (avg dosage used 50mg per day-
conventional preparations of Ampho-B)
• Course to be completed within 3-4weeks with patient
compliance often hindering completion
• Cumulative dose of 800-1000mg by the time course
completed
• Liposomal preparations 1-5mg/kg/day
• Lipid complex and Conventional preparations 0.25-1
mg/kg/day
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
57. Anti-fungals Used
Non- invasive
• Clotrimazole ( outdated)
for superficial
• Ketoconazole for
superficial
Invasive
• Amphotericin – B
• Itraconazole
• Voriconazole
• Posaconazole
• Of these Only Ampho-B
and Posaconazole used
in Mucor
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
59. Posaconazole
• Wonder drug, Expensive
• But cannot be used to initiate or used as solo drug
• Must be started after Ampho B course
• Anti-Mucor
21-Apr-17 DR.R.Malarvizhi MBBS,DLO
60. Prognosis
• Excellent in non-invasive
• Very poor in invasive ( acute > chronic)
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61. Realistic approach
• Patient compliance
• Patient education and self awareness of disease and
realistic expectations
• Patient caregiver (attender/ FAMILY) education and
realistic HOPE
• Frequent counselling to adhere to strict glymic control and
FINISH the course of Ampho B
• Some aspects cannot be predicted and some
eventualities must be explained to patient and family
BEFORE the start as well as during the course of
treatment with AmphoB
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62. • FOLLOW up is the dictum
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63. • Multidisciplinary approach and management
• Your role
• Patient compliance- foremost in successful outcome
• What and how much to give
• Know when to stop
• FOLLOW UP- for safe patient and Otolaryngologist
21-Apr-17 DR.R.Malarvizhi MBBS,DLO