Fungal Sinusitis

Nose Specialist Prof. Havas

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Fungal Sinusitis

Fungal infections in the paranasal sinuses are being increasingly blamed for causing many cases of chronic Rhinosinusitis. The evidence though is still controversial. Most fungal infections are benign or non-invasive except when they occur in individuals who are immuno-compromised.

Distinguishing invasive disease from non-invasive disease is important because the treatment and prognosis for each is very different.

Non Invasive Fungal Sinusitis

Fungal Ball

There are two forms of non-invasive fungal sinusitis; allergic fungal sinusitis and sinus mycetoma (fungal ball). Most commonly aspergillus fumigatus and bipolaris species caused allergic sinusitis. Aspergillus fumigatus and dematiaceoous fungi most commonly cause a sinus mycetoma.


Allergic Fungal Sinusitis

Allergic rhinitis is prevalent in this group of patients and is considered to be the trigger mechanism behind allergic fungal sinusitis. Patients are generally immuno-competent; often have asthma, eosinophilia and elevated total fungal specific immunoglobulin.

Allergic Fungal Sinusitis Symptoms

Allergic Fungal Sinusitis patients present with symptoms of chronic sinusitis which may include facial pressure headache, nasal stuffiness, discharge and cough. The condition should be suspected in individuals with intractable sinusitis and recurrent nasal polyps. Some may present with proptosis or decreased movement of the eye. These patients usually have atopy and have had multiple surgeries by the time their fungal sinusitis is diagnosed. CT scans of the sinuses reveal opacification of the sinuses with concretion and/or scattered calcification through them.


Sinus Mycetoma

This condition is unilateral and involves predominantly the maxillary antrum. Mucopurulent cheesy or clay like material is present at the time of surgery. Patients with sinus mycetoma are immuno-competent. Allergic conditions and fungal specific IgE are less common.

Sinus Mycetoma Symptoms

Presentation of a patient with Sinus Mycetoma is similar to that of patients with sinusitis. Examination may reveal polyposis with evidence of sinusitis occasionally one-sided. Patients report blowing out gravel like material from the nose. Usually sinus mycetoma is found incidentally on a CT scan of the brain or paranasal sinuses.


Invasive Fungal Sinusitis

Invasive Fungal Sinusitis includes the acute fulminant type which has a high mortality rate if not recognised and treated early, and aggressively, and the chronic granulomatous types. Saprophytic fungi of the order Mucorales commonly cause acute invasive fungal sinusitis.

Aspergillus fumigatus is the only fungus associated with chronic invasive fungal sinusitis and Aspergillus flavus is the only fungus that has been associated with granulomatous invasive fungal sinusitis.

Acute Invasive Fungal Sinusitis

Acute Invasive Fungal Sinusitis is the result of a rapid spread of fungus through vascular invasion into the orbit and the central nervous system. It is common in patient with diabetes and in patients who are immuno-compromised due to other causes.

Typically patients with acute invasive fungal sinusitis are severely ill with fever, cough, nasal discharge, headache and alterations in their mental status. They require immediate hospitalisation, debridement and intravenous anti fungal agents.

Acute Invasive Fungal Sinusitis Symptoms

Patients are usually hospitalised and are very sick with fever, cough, nasal discharge, headache and altered mental status. A high index of suspicion for early diagnosis is critical – particularly in immuno-compromised patients. Signs and symptoms may include ulcers on the septum or turbinates or even on the palate. In late stages the signs and symptoms of cavernous sinus thrombosis are present.


Chronic Invasive Fungal Sinusitis

Chronic Invasive Fungal Sinusitis is a slowly progressive fungal infection with low-grade invasive process and usually occurs in patients with diabetes.

Orbital Apex Syndrome which is characterised by a decrease in vision and ocular mobility due to a mass in the superior portion of the orbit, is usually associated with this condition.

Chronic Invasive Fungal Sinusitis Symptoms

Patients present with symptoms of longstanding sinusitis. Symptoms are usually not acute (no fever) and mental status remains unchanged. Orbital apex syndrome is characterised by a decrease in vision and in ocular mobility due to a mass in the superior portion of the orbit and is usually associated with this condition. Nasal examination is usually normal. Findings from the eye examination tend to be more positive.


Granulomatous Invasive Sinusitis

This condition has been reported almost exclusively in immuno-competent individuals from North Africa. Generally proptosis is associated with granulomatous invasive fungal sinusitis.

Granulomatous Invasive Sinusitis Symptoms

Patients present with symptoms of chronic sinusitis associated with proptosis. Examination of the nasal cavity is usually normal. Again findings from eye examination are usually impressive. Laboratory studies elevated serum fungus specific IgE concentrations are often found in patients with allergic fungal sinusitis. These findings are less common in patients with a sinus mycetoma.


Fungal Sinusitis Treatment

The treatment of choice for all types of fungal sinusitis is surgical. Medical treatment depends on the type of infection and the presence of invasion.

Allergic Fungal Sinusitis Treatment

Surgery is the treatment of choice. The goals of surgery are conservative debridement of the allergic mucin and polyps from the involved sinuses with restoration of normal sinus aeration. These goals are often achieved endoscopically. An external approach may be considered if the lesion is not accessible completely endoscopically. Adequate ventilation of the sinuses is essential to prevent relapse or recurrence of the disease once the disease is exenterated.

Follow Up

Long term follow-up care is required for maintenance of the sinus cavities. This may be achieved by endoscopic examination and debridement in the rooms periodically. A short course of systemic steroids may be administered if any sign of relapse or recurrence is seen. Repeated surgical debridement may be necessary if systemic steroids do not control the disease.

The best single monitor of the patient’s progress is total serum IgE levels. Each patient’s total serum IgE should be plotted after surgery. If it rises above the normal range (100) systemic oral steroid therapy should be initiated.

Sinus Mycetoma Treatment

Surgical removal of the fungus ball with the erosion of the sinus is the only requirement. Once this is accomplished no further medical treatment is indicated. Endoscopic lesion removal can be performed when the lesion is accessible.


Acute Sinusitis Treatment

Emergency surgical treatment should be performed once the condition is suspected. Such treatment is radical debridement of the necrotic tissue until normal tissue is reached. Often debridement requires an external approach. In some cases the skull base may be involved.


Chronic Invasive Fungal Sinusitis Treatment

This condition is usually less aggressive than the acute stage. Surgical debridement is warranted and can be approached endoscopically in most patients.


Chronic Granulomatous Fungal Sinusitis Treatment

Surgical debridement is the mainstay of treatment followed by systemic anti-fungal medication. Recurrence of this condition is rare.