Chronic Aspergillosis Research Articles

Performance of two Aspergillus IgG EIA assays compared with the precipitin test in chronic and allergic aspergillosis

Detection of Aspergillus IgG antibodies is important in the diagnosis of chronic pulmonary aspergillosis and allergic bronchopulmonary aspergillosis. Immunoprecipitation techniques to detect these antibodies appear to lack sensitivity and accurate quantitation compared with enzyme immunoassays (EIA). This study assessed the performance of two commercial EIAs compared with counterimmunoelectrophoresis (CIE). This was a prospective cohort study of 175 adult patients with chronic or allergic pulmonary aspergillosis. Aspergillus IgG antibodies were detected using CIE, Phadia ImmunoCap Aspergillus IgG and Bio-Rad Platelia Aspergillus IgG. Inter-assay reproducibility was determined for each method and 25 patients had two serum samples analysed within a 6-month interval. When compared with CIE, both ImmunoCap and Platelia Aspergillus IgG had good sensitivity (97 and 93%, respectively) for detection of Aspergillus IgG antibodies. The level of agreement between the two EIAs for positive results was good, but the concentration of antibodies was not correlated between the tests or with CIE titre. ImmunoCap IgG inter-assay coefficient of variation was 5%, whereas Platelia IgG was 33%. Median ImmunoCap IgG values for CPA and allergic aspergillosis were 95 and 32 mg/L, respectively, whereas Platelia IgG values were >80 and 6 AU/mL. The direction of CIE titre change over 6 months was mirrored by ImmunoCap IgG levels in 92% of patients, and by Platelia IgG in 72% of patients. Both ImmunoCap and Platelia Aspergillus IgG EIAs are sensitive measures of Aspergillus IgG antibodies compared with CIE. However, ImmunoCap appears to have better reproducibility and may be more suitable for monitoring patient disease.

Multiple Bilateral Pulmonary “Fungus Balls” in an Immunocompetent Patient Unsuitable for Surgical Treatment: Efficacy of Azoles Treatment

Data guiding management of pulmonary mycetomas are based on uncontrolled trials and case reports. Surgical resection represents a definitive treatment associated with high mortality and sometimes not feasible due to clinical conditions. We report a case of an immunocompetent patient with multiple pulmonary mycetomas, suggestive for probable chronic aspergillosis, in which surgery was contraindicated. The patient experienced a good response to long-term oral voriconazole therapy with remarkable clinical and radiological improvement at three-month follow-up. In cases of probable chronic aspergillomas, when surgery is contraindicated, long-term antifungal therapy with voriconazole seems to be a valid alternative option.

Aspergillus bronchitis without significant immunocompromise

Aspergillus bronchitis is poorly understood and described. We extracted clinical data from more than 400 referred patients with persistent chest symptoms who did not fulfill criteria for allergic, chronic, or invasive aspergillosis. Symptomatic patients with a positive culture or real-time PCR for Aspergillus spp. were reviewed. Seventeen patients fulfilled the selected criteria. Fourteen were women, with a mean age of 57 years (range 39-76). Sixteen of the patients had productive cough, eight had voluminous tenacious sputum, and seven had recurrent chest infections. Eight patients had Medical Research Council dyspnea scores of 4-5; 12 had bronchiectasis; and 13 patients grew A. fumigatus, 3 A. niger, and 1 A. terreus. Twelve of the 17 patients (71%) had elevated Aspergillus IgG (47-137 mg/L, mean 89.2) and 5 (29%) had elevated Aspergillus precipitins. Six of 12 (50%) had a major response to antifungal therapy and five of 12 (42%) patients relapsed, requiring long-term therapy. Aspergillus bronchitis is a discrete clinical entity in patients with structural lung disease but who are not significantly immunocompromised. It is distinct from asymptomatic fungal colonization and other forms of aspergillosis, and may respond to antifungal therapy.

Voriconazole for chronic pulmonary aspergillosis: a prospective multicenter trial

Early evidence suggests the efficacy of voriconazole for chronic pulmonary aspergillosis (CPA). We conducted a prospective, open, multicenter trial to evaluate the efficacy and safety of voriconazole for proven CPA in minimally or non-immunocompromised patients. Patients had CPA confirmed by chest computed tomography (CT) and/or endoscopy, positive Aspergillus culture from a respiratory sample, and positive serologic test for Aspergillus precipitins. Patients received voriconazole (200 mg twice daily) for a period of 6–12 months and were followed for 6 months after the end of therapy (EOT). The primary endpoint was global success at 6 months, defined as complete or partial (≥50 % improvement) radiological response and mycological eradication. Forty-one patients with confirmed CPA were enrolled. All patients had A. fumigatus as the etiologic agent. By EOT, five patients had died from comorbidities and seven had discontinued voriconazole due to toxicity. The global success rate at 6 months was 13/41 (32 %): 10/19 (53 %) for chronic necrotizing aspergillosis and 3/22 (14 %) for chronic cavitary aspergillosis (p = 0.01). The respective success rates at EOT were 58 and 32 %. Clinical symptoms and quality of life also improved during treatment. Voriconazole is effective for CPA, with acceptable toxicity. The response rate is higher and obtained more rapidly in necrotizing than cavitary forms.Electronic supplementary materialThe online version of this article (doi:10.1007/s10096-012-1690-y) contains supplementary material, which is available to authorized users.

Chronic invasive aspergillosis of paranasal sinuses: A case report with review of literature

Aspergillosis of the nasal and paranasal sinuses is recognized as being second to candidiasis, among opportunistic fungal infections in immunocompromised patients. However, invasive variant in normal and mildly immunocompromised hosts is a very rare occurrence. We report one such case of aspergillosis involving paranasal sinuses in mildly immunocompromised patient.

Aspergillose pulmonaire compliquant une infection à mycobactérie atypique chez deux patients atteints de bronchopneumopathie chronique obstructive

Atypical mycobacteria and Aspergillus are opportunistic organisms responsible for severe pulmonary diseases whose development is encouraged by the presence of chronic obstructive pulmonary disease (COPD) and related immunosuppression. We report the cases of two patients, both alcoholics with emphysematous COPD, who developed chronic pulmonary aspergillosis following atypical mycobacterial infection. Patient 1 developed chronic necrotising aspergillosis several months after the diagnosis of infection with Mycobacterium avium. Patient 2 developed an aspergilloma several weeks after the diagnosis of infection with Mycobacterium xenopi. The association of these two pathologies presents diagnostic and therapeutic problems that are discussed. The development of Aspergillus pulmonary disease may complicate atypical mycobacterial infections and explain a poor response to treatment. Our two case reports suggest that a systematic search should be made for pulmonary aspergillosis during the follow-up of patients with atypical mycobacterial infection.

Early Prediction of In-Hospital Mortality of Patients with Hemoptysis: An Approach to Defining Severe Hemoptysis

Background: The severity of hemoptysis is usually assessed on the amount of blood expectorated, although no threshold has been agreed upon. Respiratory or hemodynamic failures are additional severity criteria but occur in few cases. Objectives: Early identification of the in-hospital mortality determinants might be helpful to best characterize severe hemoptysis. Methods:This is a retrospective cohort study of consecutive patients with hemoptysis admitted to the ICU of a teaching hospital during a 14-year period. The model for early prediction of in-hospital mortality was developed on a derivation sample (67% of patients) using multiple logistic regression. Calibration and discrimination of the model were tested using the remaining validation sample. A scoring system was developed for clinical use. Results: The in-hospital mortality of the 1,087 patients (age 54 years, 71% male) was 6.5% (95% CI 5–8). Chronic alcoholism, cancer or aspergillosis, pulmonary artery involvement, infiltrates involving two quadrants or more on the admission radiograph, and mechanical ventilation at referral predicted independently mortality. The model showed good concordance between predicted and observed probabilities of death and good discrimination (receiver operating characteristic curve area 0.87; 95% CI 0.82–0.92). The model-based score (chronic alcoholism, pulmonary artery involvement, and radiographic patterns, 1 point each; cancer, aspergillosis, and mechanical ventilation, 2 points each) predicted the probability of death as follows: score 0, 1%; score 1, 2%; score 2, 6%; score 3, 16%; score 4, 34%; score 5, 58%; score 6, 79%, and score 7, 91%. Conclusions: Our results provide useful information about the short-term prognosis of patients with hemoptysis, which could help design therapeutic approaches and management plans according to the risk of in-hospital mortality.

Comparative estimation of mucous membrane of maxillary sinus ultrastructural changes at aspergillosis different forms

Research objective was establishment of ultrastructural changes of mucous membrane maxillary sinus (MM MS) at noninvasive and chronic invasive aspergillosis. By methods of light, electronic microscopy and morphometry it is established, that the basic signs of endocellular reorganisation of epithelial cells at noninvasive form are decrease in squirrels-synthetic and plastic functions. On separate sites of epithelium there are the cages characterised small changes by cytoplasmatic organells. As a whole, the revealed changes testify to loss of epithelium protective and barrier properties, and as consequence, its defective participation in mucocilliar clearance. At invasive form of aspergillosis sinusitis, despite revealed single-layered metaplasia, in epithelial cells was observed fiber-synthetic and plastic processes that can specify on high reparative possibilities of epithelium.

Peripheral neuropathy in patients on long-term triazole antifungal therapy

Triazole antifungal drugs are the mainstay of treatment for patients with chronic pulmonary aspergillosis and are often used as steroid-sparing agents in patients with allergic aspergillosis. Peripheral neuropathy (PN) is a rare but reported side effect of triazole therapy in the acute management of invasive fungal infections, but its incidence during long-term triazole treatment for chronic aspergillosis is unknown. The goal of this study was to determine the incidence of PN in this context. A retrospective cohort study was carried out to collect data on all patients with chronic aspergillosis commenced on long-term triazole therapy at the National Aspergillosis Centre in Manchester between 2007 and 2010. Two hundred and twenty-two patients were commenced on triazole therapy. Ten percent developed PN after an average of 4 months. Seventeen percent of patients taking itraconazole, 9% taking voriconazole and 3% taking posaconazole developed PN. This is the first report of posaconazole-induced PN. Twenty-two episodes of PN presented as numbness or tingling in the extremities, while four episodes presented as predominant leg weakness. The majority of cases were axonal, length-dependent neuropathies that recovered after triazole medication was discontinued. Two patients had non-progressive but irreversible PN. Two patients were diagnosed with mononeuropathies. A 10% incidence of PN was observed for patients commenced on triazole therapy for chronic aspergillosis. Patients on long-term triazole therapy should be monitored for neurological symptoms. If PN is suspected, diagnosis should include nerve conduction studies, exclusion of other causes and consideration of dose reduction or cessation of therapy.

Should Voriconazole be the Primary Therapy for Chronic Invasive Sinus Aspergillosis (CISA)?

ABSTRACT Introduction Invasive sinus aspergillosis infection has been reported with increasing frequency in the last decade, especially, in immunocompromised patients with chronic invasive sinus aspergillosis (CISA). The gold standard for treatment has been wide surgical debridement, intravenous administration of antifungal agents, such as amphotericin B, but the prognosis remains poor. Newer antifungal agents are being tried but no standard treatment option with new antifungal agents has yet been established for chronic invasive fungal sinusitis. Therefore, we undertook this study to evaluate the efficacy of voriconazole in patients of chronic invasive sinus aspergillosis. Materials and methods This study is a prospective randomized unblinded study with primary aim of evaluating the feasibility and effectivity of voriconazole in patients of chronic invasive sinus aspergillosis with intraorbital or intracranial extension, and secondarily to compare voriconazole with amphotericin B therapy in patients with chronic invasive sinus aspergillosis. Observations and results Thirty-three patients who fulfilled the eligibility criteria were included in this study. There were 18 patients enrolled in group I who received amphotericin therapy and 15 patients in group II who received voriconazole therapy. Out of 33 patients, 9 patients had complete response, 10 had partial response, in eight patients disease became stable and there were seven failures. Overall 50% patients had a successful outcome in group I, whereas 60% had a successful outcome in group II receiving oral voriconazole. On comparing only in extradural group, 5/10 had a successful outcome in group I receiving amphotericin B, whereas 8/12 (66.7%) had a successful outcome in group 2 receiving voriconazole. There was significant difference between adverse reactions of the two drugs, with amphotericin B having a significant renal and cardiotoxicity as compared to voriconazole; though patients on voriconazole developed skin rashes which were transient and disappeared on completion of the therapy. Conclusion The present series demonstrates that oral voriconazole can be the primary line of therapy in chronic invasive sinus aspergillosis in carefully monitored immunocompetent cases. Multicentric, randomized studies are required to define disease definition, duration and successful outcome.

Should Voriconazole be the Primary Therapy for Chronic Invasive Sinus Aspergillosis (CISA)?

ABSTRACT Introduction Invasive sinus aspergillosis infection has been reported with increasing frequency in the last decade, especially, in immunocompromised patients with chronic invasive sinus aspergillosis (CISA). The gold standard for treatment has been wide surgical debridement, intravenous administration of antifungal agents, such as amphotericin B, but the prognosis remains poor. Newer antifungal agents are being tried but no standard treatment option with new antifungal agents has yet been established for chronic invasive fungal sinusitis. Therefore, we undertook this study to evaluate the efficacy of voriconazole in patients of chronic invasive sinus aspergillosis. Materials and methods This study is a prospective randomized unblinded study with primary aim of evaluating the feasibility and effectivity of voriconazole in patients of chronic invasive sinus aspergillosis with intraorbital or intracranial extension, and secondarily to compare voriconazole with amphotericin B therapy in patients with chronic invasive sinus aspergillosis. Observations and results Thirty-three patients who fulfilled the eligibility criteria were included in this study. There were 18 patients enrolled in group I who received amphotericin therapy and 15 patients in group II who received voriconazole therapy. Out of 33 patients, 9 patients had complete response, 10 had partial response, in eight patients disease became stable and there were seven failures. Overall 50% patients had a successful outcome in group I, whereas 60% had a successful outcome in group II receiving oral voriconazole. On comparing only in extradural group, 5/10 had a successful outcome in group I receiving amphotericin B, whereas 8/12 (66.7%) had a successful outcome in group 2 receiving voriconazole. There was significant difference between adverse reactions of the two drugs, with amphotericin B having a significant renal and cardiotoxicity as compared to voriconazole; though patients on voriconazole developed skin rashes which were transient and disappeared on completion of the therapy. Conclusion The present series demonstrates that oral voriconazole can be the primary line of therapy in chronic invasive sinus aspergillosis in carefully monitored immunocompetent cases. Multicentric, randomized studies are required to define disease definition, duration and successful outcome.

산란계에서의 전신 다발성 육아종성 Aspergillosis 발생

ChoongAng Vaccine Laboratories, Daejeon 305-348, KoreaABSTRACT A case of aspergillosis in 39-day-old layer chickens having a history of gradual emaciation and subsequently death with nervous signs such as torticollis and lack of equilibrium was documented. Based on the results from serology and polymerase chain reaction (PCR) test, this flock was not affected with known viral or bacterial diseases. On postmortem examination of the affected birds, multiple white to yellow nodules measuring 15 mm in diameter were observed in the lungs, cerebrum, liver and kidney. Microscopically, these nodules were identified as granulomatous lesions characterized by mixed population of multinucleated giant cells and lymphocytes. By periodic acid-schiff staining and nucleotide sequencing analysis, Aspergillus flavus with charac-teristic septate and branched hyphae were identified in the granuloma of lung and cerebrum. This case was a chronic and multisys-temic aspergillosis specialized to central nervous system caused by Aspergillus flavus infection in the layer flocks. (Key words : Aspergillus flavus, multisystemic infection, granuloma, layer chickens, central nervous system)To whom correspondence should be addressed : moip@cbu.ac.kr ! (Aspergillosis)#Aspergillus $%&'()*+,-,./*012+345'67'8, 69*:(;' ?, @A, BCDEFGHIJK*:LMNMOI(Chutt and Richard, 1997). -PQCC+,4.RS, TUVW, .H'O+8, XY'Z*[\), ]), ^), _)H`;0'abcOI. ! *Xde#2f*ghIJi, -,jk2f*:aba4l;mno )‡£¤‰1n ,¥¦Va\§x¨t*>)NjO4no\§‡ ?()©OI4LM OI(Clark et al., 1954). Ž *:*: ! #Œa=(«¬H, 1997), «­(®n¯, 2000; 2002), b(n>H, 2001), °±G( ²³H, 2004), ´µ(¶·¸H, 2004) E¹Mo(¶·¸H, 2006) H*:./, »¼š½¾4?, š, yšHš/« K;0'67~+,ab¨5+,LMNAI. 69«­*: ! #42f\A20%Xde'l;+,pq8,  ?E»'BA‡5+,LMNAI(®n¯, 2000; 2002). 'AA ! p'AEC9LMNMO4E i, EE*:4392fŽ}S­Eš*:_vi`

Epidemiology and antifungal resistance in invasive Aspergillosis according to primary disease: review of the literature.

Aspergilli, less susceptible to antifungals emerge and resistance to azoles have been found mainly in Aspergillus fumigatus; this has launched a new phase in handling aspergillosis. Resistant strains have currently been reported from Belgium, Canada, China, Denmark, France, Norway, Spain, Sweden, The Netherlands, UK and the USA. Centres in the UK (Manchester) and The Netherlands (Nijmegen) have described particularly high frequencies (15 and 10% respectively), and a significant increase in azole resistance in recent years. The reason of this high incidence may be due to long term azole therapy in patients with chronic aspergillosis in Manchester, and due to high use of agricultural azoles in Nijmegen. The primary underlying mechanism of resistance is as a result of alterations in the cyp51A target gene, with a variety of mutations found in clinical isolates and one genotype identified in the environmental (LH98). Reports on well documented in vitro and in vivo resistance to echinocandins are rare for Aspergillus species and resistance may be under-diagnosed as susceptibility testing is less frequently performed due to technical reasons.

Unusual Presentation of Brain Aspergillosis in Chronic Granulomatous Disease

Aspergillus is a frequently observed pathogen in patients with chronic granulomatous disease. We report on a patient with chronic granulomatous disease and severe brain aspergillosis with an unusual presentation and favorable course. We discuss the impact of this infection on morbidity and mortality, adequate therapeutic management, and the need to investigate a possible fungal infection, despite nonspecific signs.

Chronic Invasive Sinus Aspergillosis in Immunocompetent Hosts: A Geographic Comparison

To investigate potential differences in clinical presentation, histopathology, and outcomes of chronic invasive sinus aspergillosis (CISA) based on geographic region and species of Aspergillus isolated. A retrospective analysis of published cases of CISA with a comparison of North American and worldwide cases comprised a systematic search of the English language literature. Thirty-four articles were identified detailing 15 North American and 76 global cases of CISA with cranio-cerebral extension in clinically immunocompetent patients. North American patients with CISA were older, had a more rapidly progressive course, and appeared to have higher rates of treatment failure and mortality. Anatomic distribution and presenting symptoms were similar between the two groups. North American cases were mostly due to A. fumigatus, while A. flavus was the predominant pathogen worldwide. While granulomatous inflammation was a rare observation in North American cases, it was seen in the majority of cases worldwide. CISA due to A. fumigatus was encountered in older adults, was associated with a chronic inflammatory response, an accelerated clinical course, and a trend toward treatment failure and higher mortality. Patients with A. flavus were younger, demonstrated granulomatous inflammation, and pursued an indolent, clinically responsive course. Observed differences in clinical presentation, histopathology, and outcome might involve a complex interplay between the human host, Aspergillus species, and local climatic conditions.

Lupus Erythematosus-Like Lesions by Voriconazole in an Infant with Chronic Granulomatous Disease

We report the first case of lupus-like lesions in an infant with chronic granulomatous disease during the treatment with voriconazole for chronic invasive aspergillosis. The lesions disappeared with termination of the treatment.

Chronic Invasive Aspergillosis caused byAspergillus viridinutans

Aspergillus viridinutans, a mold phenotypically resembling A. fumigatus, was identified by gene sequence analyses from 2 patients. Disease was distinct from typical aspergillosis, being chronic and spreading in a contiguous manner across anatomical planes. We emphasize the recognition of fumigati-mimetic molds as agents of chronic or refractory aspergillosis.

Chronic epidural intracranial actinomycosis: A rare case

A 13-year-old boy presented with a healing ulcer over the vertex, a healed ulcer above the right eye [Figure 1A], occasional fever, weight loss, diplopia, bilateral proptosis, lagophthalmos and bilateral mild facial palsy. In hospital, he developed left-sided focal seizures and symptoms and signs of raised intracranial pressure. The skull radiograph showed a thickened frontal vault, suggestive of chronic osteomyelitis [Figure 1B]. CT brain confirmed thickening of the skull vault over the right frontal region and revealed an epidural mass in the prefrontal region that was predominantly on the right side but crossed the midline and caused a mass effect, with midline shift to the left. Also present was massive white-matter edema, with effacement of the ipsilateral ventricle and enlargement of the contralateral one [Figure 1C]. A biopsy from the scalp lesion demonstrated granulation tissue, hematoxyphilic colonies, and gram positive filamentous rods, features that were diagnostic of actinomycosis [Figure 1D]. The boy recovered well withintravenous administration of crystalline penicillin and co-trimoxazole along with oral erythromycin for six weeks, followed by oral co-trimoxazole and erythromycin for six moths. The epidural mass and skull thickening, however, persisted.Figure 1: (A) Healing actinomycotic ulcer on the forehead; (B) Skull X-ray lateral view, showing sclerotic, thickened frontal vault (C) One deeply stained haematoxyphilic actinomyces colony amidst red blood cells and granulation tissue (H&E, ×150) (D and E) Contrast enhanced CT brain scan showing thickened cranial vault, brightly enhancing epidural mass with midline shift and oedemaClinical features of chronic epidural lesions of the skull and spine can be subtle and treacherous. Signs, rather than the symptoms, of raised intracranial pressure often dominate. Spinal lesions may present earlier. Epidural mass lesions can be due to a variety of causes; these include (1) hematoma due to trauma, bleeding diathesis or venous sinus thrombosis; (2) malignant deposits from lymphoma, leukemia, multiple myeloma or chloroma; (3) chronic noninfectious granuloma due to sarcoidosis, eosinophilic granuloma, cholesteatoma, hypertrophic pachymeningitis, Wegener granulomatosis or cranial fascitis; (4) chronic infectious lesions, e.g., aspergillosis or tuberculosis (5); primary neoplasms like chondromas, chordoma, chondromyxoid fibroma, osteoblastoma, giant cell tumors of skull, Ewing sarcoma, congenital lipomatosis, histiocytosis and endometrial carcinoma. Actinomycosis, a subacute or chronic granulomatous inflammatory disease, gives rise to suppuration, abscess formation and sinuses. The most common causative agent is Actinomycosis israeli, a gram-positive, acid-fast organism with some morphological resemblance to fungi.[1] Clinical forms include oro-cervico-facial (the commonest), thoracic, abdomino- pelvic, musculoskeletal and disseminated disease. The cerebral form is rare (< 5%) and may pose a diagnostic challenge, presenting as brain abscess (67%), meningitis/ meningoencephalitis (13%), actinomycetoma (7%), subdural empyema (6%) or epidural abscess (6%). Infection spreads by the hematogenous route from lung, oral cavity, abdomen or pelvis.[23] Dense fibrosis, a pathological hallmark of actinomycosis, is usually minimal in a cerebral lesion, while features characteristic of the disease at anatomic sites elsewhere (such as draining sinuses and sulfur granules) are not seen with epidural lesions. Diagnosis is usually confirmed by biopsy. Penicillin and Erythromycin are effective against actinomyces while a closely related species, nocardia is sensitive to co-trimoxazole.

Modelling Aspergillus fumigatus infections in racing pigeons (Columba livia domestica)

In vivo modelling of aspergillosis in birds allows the evaluation of control measures and the study of host–pathogen interactions. In this study the impact of the use of different inoculation routes and immunosuppression on the course of an infection with Aspergillus fumigatus in racing pigeons (Columba livia domestica) was examined. A. fumigatus conidia were inoculated in the thoracic air sac, lung or trachea in immunocompetent or immunosuppressed pigeon squabs. Immunosuppression was induced by three dexamethasone injections before inoculation. Mortality in the A. fumigatus-inoculated groups varied between 1/4 and 4/4. The highest and more acute mortality was seen in immunocompetent pigeons inoculated in the thoracic air sac and in pigeons inoculated in the thoracic air sac or lung after immunosuppression. Pigeons inoculated in the lung or inoculated intratracheally after immunosuppression developed an aspergillosis infection with a slower course of disease and more prominent clinical symptoms. Using microsatellite length polymorphism, it was confirmed that all mycoses were caused by the inoculated strain except for one isolate in a dexamethasone-treated pigeon. In conclusion, inoculation in the lung is selected as the preferred model for chronic aspergillosis in pigeons, and inoculation in the thoracic air sac as the preferred model for acute aspergillosis. The use of immunosuppressed birds seems to be contra-indicated due to the risk of opportunistic infections.

Canine fossa approaches in endoscopic sinus surgery - our experience.

To define the role of canine fossa approach when standard endoscopic endonasal sinus surgery technique fails. Retrospective review of all endoscopic sinus surgeries performed from 1992 to 2007. Out of 1612 endoscopic sinus surgeries for various indications, CFA was used in 80 patients (4.96%) and among this 15 had bilateral procedure.The various diseases which required CFA were allergic fungal sinusitis (AFS), Fungal ball, Chronic invasive aspergillosis,antro choanal polyp, inflammatory polyp, Mucocoele and Maxillary cyst,inverted papilloma and Juvenile Nasopharyngeal Angiofibroma (JNA). Eight patients had minor complications (cheek swelling-6, facial pain-2 ) which resolved in 5 days. Canine fossa approach offers an ancillary approach to failed standard endoscopic endonasal technique thereby avoiding other more invasive procedures.