1) Mycotic diseases of the paranasal sinuses range from indolent infections in healthy individuals to lethal infections in immunocompromised people.
2) Fungal sinusitis is classified into invasive, noninvasive, and allergic types based on histopathology and clinical presentation. Invasive types can spread to nearby structures like the orbit and brain.
3) Diagnosis involves imaging like CT scans to assess bone destruction, biopsy and culture of tissue to confirm infection and identify the fungal species. Treatment depends on the type but may include antifungal drugs, surgery, and improving immune function.
Acute and Chronic Rhinosinusitis, Pathophysiology and Treatmentinventionjournals
ABSTRACT: Acute sinusitis (ARS) and chronic rhinosinusitis(CRS) is a common condition worldwide.CRS is due to the infection and inflammation of paranasal sinuses. Frequent clinical manifestations of ARS include persistent symptoms with nasal discharge or cough or both, presentation with fever accompanies purulent nasal discharge, and worsening symptoms. Complications of CRS have five stages, preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess and cavernous sinus septic thrombosis. Most acute sinusitis generally of viral origin, e,g. rhinoviruses, corona viruses,and influenza viruses. Bacterial pathogen include Streptococcus pneumonia, Haemophilus influenza and Moraxella catarrhalis. Bacteria found in biofilms have their antibiotic resistant increased up to 1000 times when compared to bacteria free living of same species. Sinusitis also results from fungal invasion in patients with diabetes, immunedeficiencies, and AIDSor transplant patients. Bacterial and viral sinusitis are difficult to distinguish. The diagnosis of acute sinusitis should be on clinical presentation in most patients CT scan of sinuses is useful for patients with complications and in patients in whom sinus surgery is considered. MRI may have a role in the diagnosis of fungal rhinitis. The benefit of Functional Endoscopic Sinus Surgery (FESS) is its ability for a more targeted approach. Recently developed treatment by balloon sinuplasty is promising. A short-course of antibiotics is helpful in clinically diagnosed bacterial sinusitis without complicating factors.
A presentation with a view on how infection spreads through the focus of dental caries into a full cellulitis. Since dentists have to deal often with large space infections, this presentation helps to review your knowledge in this subject. - Dr. Abhishek John Samuel, MDS, Endodontics
fter black fungus infection being called an epidemic and a notifiable disease in some states, medical experts have cited alarms over the discovery of a white fungal infection.
Considered to be more deadly and lethal than black fungus, reports suggest that at least 4 cases pertaining to the white fungus infection have been detected in Patna, Bihar and many more might be undiagnosed at this stage.
Rhinisinusitis bullet point,type,causative organism,investigation,treatment
quick overview ,easy understanding
ref:Scott-Brown's Otorhinolaryngology and Head and Neck Surgery
ENT Nasal septal perforation..... for best rhinoplasty and nose reshape surgery contact
Dr Junaid Ahmad (MBBS FCPS) is the best plastic surgeon in Lahore. He is a well known, trained and expert in his field. He is MBBS and FCPS in Plastic and Recosntructive Surgery. He is a post graduate of the College of Physicians and Surgeons Pakistan which is oldest and best institute for post graduation in this area of the world. He is doing his practice in Lahore, Pakistan. He is always kind to the patients and listens them carefully as it is part of modern clinical skill and training. He is expert in both cosmetic as well as reconstructive surgery. He is also skin cancer and burn expert. A few of Dr Junaid Ahmad expertise are listed here..... call 03104037071
Acute and Chronic Rhinosinusitis, Pathophysiology and Treatmentinventionjournals
ABSTRACT: Acute sinusitis (ARS) and chronic rhinosinusitis(CRS) is a common condition worldwide.CRS is due to the infection and inflammation of paranasal sinuses. Frequent clinical manifestations of ARS include persistent symptoms with nasal discharge or cough or both, presentation with fever accompanies purulent nasal discharge, and worsening symptoms. Complications of CRS have five stages, preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess and cavernous sinus septic thrombosis. Most acute sinusitis generally of viral origin, e,g. rhinoviruses, corona viruses,and influenza viruses. Bacterial pathogen include Streptococcus pneumonia, Haemophilus influenza and Moraxella catarrhalis. Bacteria found in biofilms have their antibiotic resistant increased up to 1000 times when compared to bacteria free living of same species. Sinusitis also results from fungal invasion in patients with diabetes, immunedeficiencies, and AIDSor transplant patients. Bacterial and viral sinusitis are difficult to distinguish. The diagnosis of acute sinusitis should be on clinical presentation in most patients CT scan of sinuses is useful for patients with complications and in patients in whom sinus surgery is considered. MRI may have a role in the diagnosis of fungal rhinitis. The benefit of Functional Endoscopic Sinus Surgery (FESS) is its ability for a more targeted approach. Recently developed treatment by balloon sinuplasty is promising. A short-course of antibiotics is helpful in clinically diagnosed bacterial sinusitis without complicating factors.
A presentation with a view on how infection spreads through the focus of dental caries into a full cellulitis. Since dentists have to deal often with large space infections, this presentation helps to review your knowledge in this subject. - Dr. Abhishek John Samuel, MDS, Endodontics
fter black fungus infection being called an epidemic and a notifiable disease in some states, medical experts have cited alarms over the discovery of a white fungal infection.
Considered to be more deadly and lethal than black fungus, reports suggest that at least 4 cases pertaining to the white fungus infection have been detected in Patna, Bihar and many more might be undiagnosed at this stage.
Rhinisinusitis bullet point,type,causative organism,investigation,treatment
quick overview ,easy understanding
ref:Scott-Brown's Otorhinolaryngology and Head and Neck Surgery
ENT Nasal septal perforation..... for best rhinoplasty and nose reshape surgery contact
Dr Junaid Ahmad (MBBS FCPS) is the best plastic surgeon in Lahore. He is a well known, trained and expert in his field. He is MBBS and FCPS in Plastic and Recosntructive Surgery. He is a post graduate of the College of Physicians and Surgeons Pakistan which is oldest and best institute for post graduation in this area of the world. He is doing his practice in Lahore, Pakistan. He is always kind to the patients and listens them carefully as it is part of modern clinical skill and training. He is expert in both cosmetic as well as reconstructive surgery. He is also skin cancer and burn expert. A few of Dr Junaid Ahmad expertise are listed here..... call 03104037071
ABSTRACT
Background: With the advances in medical care, invasive fungal
infections possess a significant health problem especially in
immunocompromised patients. These infections have varied aetiological
agents which are commonly found in soil, water, plant debris and organic
substrates. Aim: The overview of different fungal aetiological agents,
newer and rapid diagnostic modalities and overall treatment and
prevention options available is presented in this article. Methods:
Literature search was performed in PubMed by using MeSH terms
‘mycoses’ and ‘immunocompromised host’. Only relevant review articles
published within the last five years were considered. Google Scholar
search engine was also used. Results: Common invasive fungi include
Candida spp., Cryptococcus spp., Aspergillus spp., Trichosporon spp.,
Rhodotorula spp., Fusarium spp., Mucormycotina, Pheohyphomycosis
spp., Pneumocystis jirovecii, Scedosporium spp., and endemic mycoses
such as Penicillium, Histoplasma and Blastomyces. A high degree of
suspicion is required for early diagnosis and optimal management of these
infections. Conclusion: Early and rapid diagnosis of causative fungal
agents is required so that appropriate treatment can be initiated. Adequate
preventive measures must be applied in an immunocompromised host that
can prevent development of drug resistant super-infections.
—Fungal organisms are ubiquitous. A common location for these organisms to enter the human body is through the external acoustic canal, oral cavity, and pharynx and sino-nasal cavity. A study was conducted with clinical and mycological analysis of various fungal infections in ENT. Patients suspected for having fungal infections attending at Department of ENT were interrogated and analysed. Swabs collected from these cases were sent for direct microscopy by KOH mounts for fungal examination and fungal culture. Microbiological confirmed 100 cases were finally included in the study Histopathological examination of nasal mass and polyposis was also done. It was observed in this present study otomycosis was most common and accounted for 84% of the total cases followed by candidiasis in oral cavity and pharynx in 9%, allergic fungal rhinosinusitis in 4% and rhinosporidiosis in 3%. Aspergillus niger was that most common fungus isolated in 61% cases, followed by Candida albicans in 24% cases, Aspergillus flavus in 9% cases, Aspergillus fumigatus and Rhinosporodium seeberi in 3% cases each. All the cases of fungal infection of oral cavity and oropharynx were due to Candida albicans.
1. Mycotic diseases of the paranasal
sinuses
Mycotic diseases of the paranasal sinuses range from an indolent infection in an otherwise normal
person, to a lethal fulminant infection in an immunocompromised individual.
Based on histopathological finding & clinical presentation, fungal sinusitis is now classified into three
categories: invasive sinusitis, noninvasive sinusitis & allergic fungal sinusitis.
Invasive fungal sinusitis
Definition : invasive fungal sinus disease can be subdivided into the following three syndromes:
acute fulminant invasive sinusitis,chronic invasive sinusitis & chronic granulomatous invasive
sinusitis(paranasal granuloma).
1) Acute invasive sinusitis: acute fulminating (invasive) fungal sinusitis is a rapidly progressive
disease that is most commonly seen in immunocompromised individuals or diabetes. The
infection can spread from the nasal mucosa & sinus into orbit & brain. The aetiological
agents have a predilection for vascular invasion causing thrombosis, infarction& ischaemic
necrosis of tissue. Blood vessels invasion is seen histologically.
2) Chronic invasive sinusitis: chronic (invasive) sinusitis is a slowly progressive disease that is
seen in both immunocompromised or immunocompetent individuals. This condition may be
begin as a paranasal sinus fungus ball.(non-invasive fungal sinusitis) then become invasive,
perhaps as result of the immunosuppression associated with diabetes mellitus or
corticosteroid treatment. If untreated, the infection can spread to invade adjacent
structures including the orbit & brain. The most common agent are Aspergillus, bipolaris&
curvularis species. Itraconazole 100mg/bd result in remineralization of the eroded skull
bone.
3) Chronic granulomatous invasive sinusitis: granulomatous invasive fungal sinustitis is a
slowly progressive disease that occurs in immunocompromised persons who often have had
chronic sinusitis. There is profuse fungal growth with localised tissue invasion, noncaseating
granulomas with giant cells. The granulomatous response is often intense enough to cause
pressure necrosis of bone & can spread to orbit & brain. Most cases reported in North
Africa. Most common agent is A.flavus. surgical removal of granuloma is difficult. Medical
treatment itraconazole 100mg/bd.
Aetiological agents
Many different organisms have been implicated as aetiological agents of invasive fungal sinusitis.
However the commonest causes of acute fulminant sinusitis are moulds belonging to the order
mucorales. Others less frequent causes aspergillus species.
Many of these organisms are ubiquitous in the environment, being found in the air, in the soil& on
decomposing organic matter, others are plant poathogens.
2. Epidemiology
The aetiological agents that infection will occur following inhalation of fungal spores largely
depends on host factors. Prolonged neutropenia & metabolic acidosis are well recognised as an
important risk factors for rhinocerebral mucormycosis & fulminant aspergillus sinusitis among
patients with haematological malignancies & diabetes mellitus. Others contributing factors include
the use of corticosteroids & AIDS.
Clinical manifestations
In immunocompromised persons, acute invasive fungal sinusitis presents with fever, unilateral facial
swelling, unilateral heahache, nasal obstruction or pain & a serosanguinous nasal discharge. Necrotic
black lesions on the hard palate or nasal turbinate are a characteristic diagnostic sign.
Many patients present with a history of nasal obstruction & chronic sinusitis. Thick nasal polyposis &
thick purulent mucus are common. If infection spread from ethmoid sinuses into orbit, the orbital
apex syndrome is a common clinical presentation.
Diagnosis
Plain x-ray are insensitive & donot allow distinction between bacterial & fungal infections.
CT scanning can be used to assess the extent of bone destruction. MRI is not superior to CT.
1) The commonest finding of acute invasive fungal sinusitis include involvement of several
sinuses but with unilateral predilection, no air-fluid level, thickening of sinus lining&
destruction of bone.
2) In patient with chronic invasive sinusitis, CT scan shows a hyperdense mass (owing to a
dense accumulation of fungal hyphae) within the involved sinus with erosion of sinus wall.
3) The most common CT scan finding in patient with granulomatous invasive fungal
sinusitis(paranasal granuloma) are opacification of ethmoid, maxillary or all sinuses,
together with erosion of bone.
Local biopsy & histopathological examination & culture of tissue or sinus contents confirm the
clinical & radiological diagnosis.
Microscopic examination of smear ( potassium hydroxide preparation ) material taken from necrotic
lesions.
Isolation of aetiological agent in culture is essential for the species of fungus involved to be
identified.
Management
If treatment of acute invasive fungal sinusitis is to be successful, a prompt diagnosis is essential.
Correction of acidosis is essential & immunosupresive drugs should be reduced in dose. Infected &
necrotic material removed immediately. In acute fulminant fungal sinusitis with invasion of blood
vessels amphotericin B has been considered the drug of choice. Newer lipid based formulation of the
drug, in high doses of liposomal amphotericin B (10-15mg/kg per day) should be considered the first
3. line of treatment. This should be continued until the patient recovers ,at least until the progression
of disease ceases& underlying disorder is well controlled. Patient with amphotericin B should be
monitored for signs of renal damage. Other treatment options are administration of hyperboric
oxygen, iron chelators & cytokine.
Chronic invasive sinusitis, a histological diagnosis is needed to exclude blood vessel invasion in acute
fulminant fungal sinusitis. Extensive surgical debridement with removal of all necrotic material
combined with antifungal treatment has been recommoned. The optimum duration of itraconazole
200mg/bd has not been defined. The role of newer triazole antifungal agents such as itraconazole,
voriconazole& posaconazole, is unclear but promising. There is evidence that long-term treatment
can reduce the rate of recurrence following surgical resection or cure the condition on its own.
Itraconazole 200mg/bd has made surgery unnecessary in most cases. It is important to exclude
fulminant acute sinusitis by histology(invasion of blood vessels).
Noninvasive fungal sinusitis
Definition : a paranasal sinus ball(or sinus mycetoma) is a chronic noninvasive fungal infection that is
seen in immunocompetent persons. However, if immunocompromise should occur, then the
condition may become invasive & life-threatening. Fungus ball consists of a dense mass of fungal
hyphae. They are sometimes found in the sinus cavities of patients undergoing investigation for
chronic sinusitis, nasal obstruction, facial pain or other conditions.
Aetiological agents
Aspergillus fumigates is the most frequently isolated organism. These moulds are ubiquitous in the
environment. Less commonly A.flavus, S.apiospermum& Alternaria speices have been incriminated.
Epidemiology
Older individuals are appear to be more suspectible. No case have been reported in children. The
incidence of allergic rhinitis is no higher than in the general population.
Clinical features
Affected persons often present with long-standing symptoms of nasal obstruction, purulent nasal
discharge, cacosmia(fetid smell) or facial pain. The symptoms are often unilateral. Maxillary sinus is
most commonly involved, with partial or complete opacification, bone thickening & sclerosis;
occasionally bone destruction can occur. The sphenoid sinus is second most common site of
involvement.
Diagnosis
CT scans should reveal partial or total opacification of the involved sinus, often associated with
flocculent calcifications.
Histopathological investigation reveal material composed of a dense matted conglomeration of
fungal hyphae, separate from but adjacent to the mucosa of the sinus. No evidence of allergic mucin
in the sinus or granulomatous reaction in the mucosa. There should be no fungal invasion of the
mucosa, associated blood vessels or bone.
4. Management
Surgical removal of the fungus ball is the treatment of choice. No local or systemic antifungal
medication is needed.
Outcome & complications
Recurrence is rare but has been described as late as two years following the endoscopic removal of a
paranasal fungal ball. Patients who become immunocompromised are at risk of developing an
invasive fungal sinusitis.
Allergic fungal sinusitis
Definition : allergic fungal sinusitis is a non invasive disorder, seen in immunocompetent individuals,
which is increasingly being recognised as a cause of chronic rhinosinusitis. This disorder range from 5
to 10% of patients with chronic rhinosinusitis.
The diagnostic criteria of this condition are following: the presence in patients with chronic
rhinosinusitis (confirmed by CT), allergic mucin containing clusters of eosinophils& byproducts,
fungal hyphae on staining or culture.
Most experts also require the presence type 1 hypersensitivity to cultured fungi & nasal polyposis.
The diagnosis of allergic fungal sinusitis should not, however, be established or eliminated, on the
basis of results of the fungal cultures because of the vriable yield of these cultures.
The term eosinophilic mucin rhinosinusitis has been proposed to describe those patients with
chronic rhinosinusitis & allergic mucin in whom no fungal elements can be detected. It represent a
heterogenous group of pathophysiology mechanism all associated with eosinophilia, but in which
the predominant mechanism is a systemic dysregulation of immunological control.
It has been suggested that allergic fungal sinusitis is an allergic response to fungi in predisposed
individual.
Aetiological agents
In earlier reports, Aspergillus species were believed to be predominant cause of allergic fungal
sinusitis. More recently it is due to various dematiaceous environmental moulds, including
Alternaria , Bipolaris,Cladosporium, Curvularia & Drechslera speices.
Epidemiology
This condition occurs in young immunocompetent adults with chronic relapsing rhinitis,
unresponsive to antibiotics, antihistamines or corticosteroids. Although patients do not have
underlying immunodeficiencies, 50-70% are atopic. There is no male or female predominance.
Laregest number are reported in warm humid areas of the southern America where disorder
accounts for about 7% of all sinus surgeries.
Clinical manifestations
Many patients with allergies fungal sinusitis have a history of chronic rhinosinusitis & have
undergone multiple operations prior to diagnosis.
5. Patients present with unilateral nasal polyposis & thick yellow-green nasal or sinus mucus. Nasal
polyposis may form an expansive mass that causes bone necrosis of the thin walls of the sinuses.
Diagnosis
The diagnosis of allergic fungal sinusitis requires the presence of chronic rhinosinusitis in an
otherwise immunocompetent individual.
Laboratory test for eosinophilia, total serum IgE, specific IgE aganist fungal antigens,positive skin
prick test to fungal antigens.
CT scanning to assess the extent of disease.
Microscopic examination of the allergic mucin(either at the time of surgical debridement for chronic
rhinosinusitis or endoscopic examination for drainage) to determine the presence of eosinophils &
fungal elements.
Histological examination of sinus tissue to rule out invasion.
Fungal cultures are used to identify the responsible fungus.
The criteria for diagnosis are
-characteristic allergic mucin
- clusters of eosinophils
-Charcot layden
-the presence of fungal hyphae
- the presence of type 1 hypersensitivity.
Management options
Surgical debridement to remove the polyps & allergic mucin. Adjunctive medical treatment is also
required because all fungal element can not be removed. Commonly medical treatment nasal
corticosteroids, antihistamine, antileukotrienes sinonasal saline lavage & specific allergen
immunotherapy. Systemic antifungal treatment is ineffective on its.
Outcomes & complications
Postoperative endoscopic follow up is recommended because there is poor correlation between
subjective improvement & presence of objective regression of disease.
Despite surgical debridement & corticosteroid treatment, the condition may recurs upto 2/3rd of the
patients.
6. Candidiasis
The term candidiasis is used to refer to infections caused by organisms belonging to the genus
Candida. These opportunistic pathogens can cause acute or chronic deep seated infection, but more
often seen causing mucosal, cutaneous or nail infection. Oropharyngeal candidiasis is a commom
problem in debilited or immunocompromised persons. Isolated largyngeal candidiasis can also occur
in these individuals, but is much less common.
Epidemiology
Candidia albicans is present as a commonsal in the mouth of the adult populations. The number of
organisms in the saliva of carriers increases with tobacco smoking & dentures are worn.
Predisposing factors : debilitated patients such as those reciveing broad-spectrum antibiotic or
corticosteroids, DM, severe nutritional deficiencies, immunosuppressive disease(AIDS).
Local factors: unhygienic or ill-fitting dentures, tobacco smoking.
Prior to the introduction of combination antiretroviral treatment, oropharyngeal candidiasis was the
most common opportunistic infection seen in patients with HIV infection.
Clinical manifestations
Oral candidiasis can be classified into a number of distinct clinical forms.
-pseudomembranous candidiasis;
-erythematous (atrophic) candidiasis;
-hyperplastic( candida leukoplakia) candidiasis.
1) Pseudomembranous candidiasis is an acute infection, but can occur steroid inhalers,
immunocompromised individuals. It can also seen in neonates & terminally ill patients(leukaemia/
malignancies.), HIV patient. The lesion is painless although mucosal erosion or ulceration can occur.
The infection may spread to involve the throat, giving rise to severe dysphagia. The simple test is to
determine whether the pseudomembrane can be dislodged. If it can be wiped off to reveal an
eroded, erythematous & sometimes bleeding base, then this is diagnostic for pseudomembranous
candidiasis.
2) Erythematous candidiasis(atrophic candidiasis): is often associated with broad-spectrum
antibiotic treatment, chronic corticosteroid use& HIV infection or persistent pseudomembranous
candidiasis.
It can affect any part of the oral mucosa & manifests as a flat, red lesion, usually on the palate or
dorsum of the tongue. Lesion on the tongue present as depapillated areas.
3)Hyperplastic candidiasis(candidia leukoplakia): the lesion can undergo malignant transformation.
The lesion range from small palpable, translucent white areas to large dense opaque plaque, hard
rough on palpation. These lesion can not be removed. The lesion usually occur on the inside surface
of one or both checks, less commonly on the tongue. They are usually asymptomatic. Lesion that
7. contains both red erythroplakic & white leukoplakic areas must be regarded with great suspicion as
malignant change is often present.
4) chronic atrophic candidiasis or denture stomatitis: chronic mucosal erythema is associated with
oral prostheses.
Diagnosis
The clinical manifestation of oropharyngeal candidiasis are often characteristic, but can be confused
with other disorders. The diagnosis should be confirmed by microscopic examination & cultures.
Management
In infant pseudomembranous candidiasis can be treated with nystatin oral suspension
(100000units/ml) or amphotericin B oral suspension(100ml/ml). These should be dropped into
mouth after each feed or at 4 to 6 hours intervals. In most cases, the lesions will clear within two
weeks.(oral amphotericin B is not absorbed through the gut).
Older children & adults with nystatin/ amphotericin B oral suspension ( 1ml at six hour interval for
2/3 weeks). Or miconazole oral gel (250mg at six hour intervals). Treatment should be continued for
at least 48hours after all lesions have cleared & symptoms have disappeared.
Oral fluconazole (100-200mg/day) for 7 to 14 days than itraconazole & ketoconazole. Refactory
candidiasis can be managed with parenteral amphotericinB(.3-.5mg/kg per day for one week or
caspofungin(50mg/day)
The treatment of choice for laryngeal candidiasis is perenteral amphotericin B(.7-1mg/kg per day).
Airway obstruction managed by endotracheal intubation.
To reduce the likelihood of resistance developing, long-term azole treatment should be avoided
unless relapse is frequent or disabling.
The patient unresponsive to azole treatment can be managed with amphotericin B or
caspofungin.