1. Fungal rhinosinusitis
Noninvasive fungal sinusitis or rhinosinusitis
1)Fungus ball:
Previously referred to incorrectly as mycetomas , well defined as the presence of tangled mats of
hyphae in one or more sinus cavities, occurs in immunocompetent patients without invasion of the
mucous membrane.(Aspergillus fumigatus is the most common fungus& aspergillus flavus may be
found)
Only adults with a female predominance are affected & no paediatric cases have been reported.
Geographical factors such as humidity.Maxillary sinus followed by sphenoid sinus are the main
locations.
Persistent symptoms such as post-nasal discharge (Green-brown) & cacosmia are the most common
clinical presentation but patient may be asymptomatic.(i.e. Chronic rhinosinusitis).Often unilateral
nasal obstruction.
CT scan shows heterogeneous opacification with bony thickening or sclerosis of the sinus wall.
Diagnosis is confirmed by histopathology, dense accumulations of fungal elements in a mucoid
matrix. No mucosal involvement as it is an extramucosal disease.
Treatment : surgical removal of the fungus ball by endoscopic guidance. The fungus ball is aspirated
away from the underlying mucous membrane. No medical treatment is required. Prognosis
excellent.
2)Allergic fungal rhinosinusitis
Allergic fungal rhinosinusitis , is the strictest sense, is defined as an immonucompetent patient with
an allergy to fungus.It has similar aetiology to allergic bronchopulmonary aspergillosis. The
pulmonary pathology concerns only aspergillus although for AFRS, the most common fungi are
dematiaceous species(Bipolaris,Curvularia, Alternaria) & more rarely Aspergillus.
Geographic area are more commonly where the climate is warm& humid but warm dry climates can
also be associated with this pathology.
Pathophysiology : inhalation of ubiquitous fungi in eases of atopic patients provokes an antigenic
stimulus(type I hypersensitivity) & an inflammatory response of the mucous membrane. Resulting
oedema is associated with the production of allergic mucin defined as a thick green to grey
lamellate of dense inflammatory cells, mostly eosinophils, in various stage of degranulations,
charcot-leyden crystals &fungal hyphae.

2. Clinical presentation
Most patients are younger age group (approximately 30years), either male or female. Usually
bilateral but unilateral . chronic pansinusitis, polyps are present in the nose associated complete
opacifications of the sinus cavities, proptosis of eyes.
Diagnosis
The presence of hyphae in the mucin associated with eosinophils is one of major criteria for the
diagnosis. Culture is necessary to identify the actual fungal agent but no growth is frequently
observed. Skin prick test & radioallergosorbent test (RAST). Others investigations, such as total
eosinophils count, total serum IgE, antigen specific IgE.
CT scaning ; complete opacification of the sinus cavities with bony expansion or extension.
Nasal endoscopy:
Stage I Mucosal oedema with or without allergic mucin
Stage II polypoid oedema with or without allergic mucin
Stage III sinus polyps with fungal debris or allergic mucin.
Treatment
Debridment of all allergic mucin
Prednisolone (length &dose are not clearly defined)
Topical intranasal steroid is prescribed for at least one year.
Topical & systemic antifungal are not recommended as sufficiently efficacious in this condition.
Prognosis
Recurrence is common.
Invasive fungal rhinosinusitis
1)Chronic or indolent invasive fungal rhinosinusitis
Invasive fungal rhinosinusitis is probably one of the less frequent forms of fungal rhinosinusitis, most
of them being affected in north Africa & asia. Two forms: granulomatous & non-granulomatous
based on the presence or absence of granulomas within tissue.
Caused by A.fumigatus/flavus in immunocompetent patients.
Clinical presentation where pain is the main symptom(Orbital apex syndrome). An asymptomatic
period frequently occurs .Symptoms appearing only when the orbit or skull base are involved.
Chronic headache, unilateral proptosis & cranial nerve deficits have been reported.

3. Diagnosis
Radiological appearances usually show opacification with bone erosion extending to the orbit &/or
skull base.
Nasal endoscopy reveals nasal congestion or polypoid mucosa . Sometimes a soft tissue mass
covered by a normal or ulcerated mucosa.
Histopathology :
Granulomatous type;Granuloma with multinucleated giant cells& pallisaded histiocytes.
Nongranulomatus type; Necrosis of mucosa, submucosa, blood vessels, or bone with low grade
inflammation.
Treatment
Radical debridment with antifungal agents.
Prognosis
Good but disease can recur.
2)Acute fulminate fungal rhinosinusitis
This is characterized by a mycotic infiltration of the mucous membrane of the nasal cavity &/or
paranasal sinus. It occurs in immunocompromised patients (AIDS, haematologic disease, type I
diabetes mellitus) with a fatal outcome in absence of treatment. An early detection of the disease is
essential especially when the CD4 cell count are notably depressed.
Common fungi are mucorales & aspergillus. Fungi show a marked predilection for vascular invasion
with invasion of the wall of large & small arteries & vein causing thrombosis.
Clinical presentation
Initial symptoms are subtle,fever of unknown origin ,rhinorrhoea & crusting of the nasal mucosa
are the most common symptom. Later proptosis, ophtalmoplegia & focal neurological signs occur.
Diagnosis
CT & MRI may be normal in early stage, necessity for a careful endoscopic evaluation.
Nasal endoscopy is the crux of the diagnosis to discolouration (often a black necrotic turbinate),
granulation tissue, crusts or ulceration in the nose. The most frequent sites of involvement are near
the middle turbinate , the septum & more nearly the inferior turbinate.
Treatment
Aggressive surgical debridment, antifungal agents,treatment of underlying conditions. Amphotericin
is the conventional therapy especially for mucormycosis.
Prognosis
Fair when disease is limited to sinus, poor with intracranial involvement.

4. Key note:
Allergic fungal rhinosinusitis usually presents with nasal polyposis, tenacious allergic mucin with
intensely eosinophilic contain few fungal hypae on silver staining. CT scan shows evidence of
hyperdense regions due to chelation of metals.