Abstract
Background: Fungal rhinosinusitis (FRS) with mucosal invasion is not classified by the current criteria, and clinical reports on the topic are limited. The aim of this study was to present our 25-year experience on fungal balls with mucosal invasion that do not appear in the FRS classification. Methods: Of 1318 patients who underwent endoscopic surgery with paranasal FRS between November 1994 and July 2019, 372 underwent mucosal biopsies. Medical chart and pathology review were performed on 13 patients diagnosed as having fungal balls with mucosal invasion without accompanying tissue invasion. Results: Histopathologic findings identified all fungi as belonging to the Aspergillus species. In 13 patients, 7 fungal balls were located in the maxillary sinus, 3 in the sphenoid sinus, and 3 in both the maxillary and ethmoid sinuses. The median age at diagnosis was 67 years (interquartile range (IQR): 62–72), and the sex ratio was 1:2 (4 men and 9 women). Five patients had comorbidities—three with diabetes mellitus and two with hematologic malignancy—all of whom received postoperative antifungal therapy. The median duration of antifungal treatment was 13 weeks (IQR: 8–17). No recurrences occurred during the median follow-up period of 30 months (IQR: 22–43). Conclusions: Patients who have been clinically diagnosed with a fungal ball and showed mucosal invasion but no vascular invasion, based on pathologic findings after surgery, may need a new FRS classification category, such as microinvasive FRS, and adjuvant antifungal treatment may be needed for immunocompromised patients with microinvasive FRS. Key points: Fungal rhinosinusitis with mucosal invasion is different from fungal ball and invasive fungal rhinosinusitis and may be classified in a separate category as microinvasive FRS.
Highlights
Fungal rhinosinusitis (FRS) exhibits various clinical characteristics, ranging from colonization to life-threatening invasive disease
Invasive FRS is divided into subtypes according to the disease duration, whereby acute invasive FRS develops within 4 weeks and chronic invasive FRS lasts more than 12 weeks
Invasive FRS requires immediate antifungal treatment after surgery, whereas in case of fungal balls, endoscopic surgical removal is sufficient without the need for additional antifungal therapy [12]
Summary
Fungal rhinosinusitis (FRS) exhibits various clinical characteristics, ranging from colonization to life-threatening invasive disease. The International Society for Human and Animal Mycology classified the invasive and non-invasive types according to histologic findings According to this classification, invasive diseases include acute invasive (fulminant), granulomatous invasive, and chronic invasive FRS, whereas the non-invasive diseases include saprophytic fungal infestation, fungal balls, and fungus-related eosinophilic FRS, including allergic FRS [2]. Fungal rhinosinusitis (FRS) with mucosal invasion is not classified by the current criteria, and clinical reports on the topic are limited. Conclusions: Patients who have been clinically diagnosed with a fungal ball and showed mucosal invasion but no vascular invasion, based on pathologic findings after surgery, may need a new FRS classification category, such as microinvasive FRS, and adjuvant antifungal treatment may be needed for immunocompromised patients with microinvasive FRS.
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