Chronic Fungal Sinusitis Research Articles

Chronic sinusitis

Sinusitis is a very common chronic illness with a substantial health care impact. This review focuses on factors contributing to sinusitis pathogenesis and chronicity, including anatomic factors, disturbances in mucociliary clearance, microbial pathogens, and inflammatory factors. A distinction is made between “infectious” and “noninfectious” types of inflammation in chronic sinusitis. The inflammatory characteristics of noninfectious inflammation are reviewed primarily in the context of chronic hyperplastic sinusitis with nasal polyposis. Key features of this type of inflammation include the presence of chronic inflammatory cells, large numbers of eosinophils, and IL-5–producing T lymphocytes. Allergic fungal sinusitis is discussed as a special type of chronic sinusitis. Published studies on the outcomes of medical management are reviewed. Finally, algorithms for medical management of chronic sinusitis and allergic fungal sinusitis are presented. (J Allergy Clin Immunol 2000;106:213-27.)

Fungal colonization of the paranasal sinuses.

Fungal infection of the paranasal sinuses occur in four primary types: acute invasive (1), chronic invasive (2), chronic fungus ball (3) and allergic fungal sinusitis (4). The first and second form can be fatal and is often found in immunosuppressed patients. The present paper concerns a group of immunocompetent patients with non-invasive chronic sinusitis caused by moulds. Over the period from 1994 to 1998, 132 tissue samples from the paranasal sinuses obtained by endoscopic operation from 117 patients was examined for mycotic infections. The mycological examination was carried out if granulomatous and crumbly material was seen in the sinus by endoscopy (91 times maxillary sinus, 23 times ethmoid sinus, 11 times frontal sinus, 7 times sphenoid sinus). Out of 117 patients 29 were positive (24,9%). From 132 surgical specimens fungi were proved in 34 times (25,7%). The following fungal species were isolated: Aspergillus fumigatus 17 times, other Aspergillus spp 6 times, Alternaria alternate 2, Penicillium rugulosum 1, and moulds without differentiation 5 times. In the histological examination an invasive mycelial growth in the mucous membrane or in the bones was never observable. Our findings represented a commensal colonization of the paranasal sinuses, but not a mycosis. The colonization is evidently assisted by a chronic hyperthrophic sinusitis with increased mucus production which impedes the mucociliary clearance. For immunosuppressed patients, however, this situation causes a danger of invasion with fatal consequences.

Diagnostic criteria for sarcoidosis of the sinuses

Background: Although newer technologies facilitate its diagnosis and treatment, little is known about sarcoidosis of the paranasal sinuses. Objectives: We sought to better characterize sarcoidosis of the sinuses and establish criteria for diagnosis. Methods: Case-finding criteria were established, and over 50 reports of sarcoidosis of the sinuses in the medical literature were reviewed. Nine case reports of patients fulfilling the case-finding criteria were identified, as were 6 additional patients from our clinics. Results: Nasal obstruction and chronic sinusitis were the usual initial complaints from patients and were associated with mucosal crusting, studding, plaque-like changes, or polyps in the nose in 5 of 6 of our patients. The most consistent finding in nose and sinuses was an erythematous, edematous, friable, hypertrophied mucosa. Like 5 of 6 of our patients, most patients had extra-pulmonary sarcoidosis involving multiple organs, but some had isolated upper respiratory disease. Radiologic studies showed extensive and often complete opacification of the sinuses and nose similar to that seen in diffuse polyposis associated with chronic bacterial and fungal sinusitis. No specific histopathologic findings distinguished sinus disease from those reported with pulmonary involvement. Pharyngeal involvement was present in 2 case reports and caused the apparent asphyxiation of 1 of our patients. Conclusion: Sarcoidosis of the sinuses should be considered in the differential diagnosis of sinusitis, especially in association with nasal polyposis, even when the sarcoidosis has not been otherwise diagnosed. On the basis of this experience, we propose diagnostic criteria for sarcoidosis of the sinuses. These include (1) radiologic evidence of sinusitis, (2) histopathologic confirmation of noncaseating granuloma in the sinus tissue supported by negative stains for fungus and acid-fast bacilli, (3) negative serologic test results for syphilis and antineutrophil cytoplasmic antibodies, and (4) no clinical evidence of other disease processes associated with granulomatous nasal and sinus inflammation. These criteria will provide the basis for further studies to assess both the natural history and the effectiveness of treatment in sarcoidosis of the sinuses. (J Allergy Clin Immunol 1999;103:789-95.)

Chronic mycoses of the paranasal sinuses--value of endonasal paranasal sinus surgery

Many host factors even in immunocompetent patients may have an influence on development of a fungal diseases within the paranasal sinuses. Fungal sinusitis can occur in an acute form or more often to a chronic type of the disease. These mainly relatively asymptomatic chronic forms and further divided into a chronic noninvasive, chronic allergic, and chronic invasive disease. Endonasal microsurgery has significantly changed the management of chronic fungal sinusitis and allows adequate removal of pathologic tissue even in advanced situations. The aim of this study was to analyze the efficacy of endonasal surgery in chronic fungal sinusitis. In a retrospective study we assessed a group of 40 patients who had endonasal surgery for chronic fungal sinusitis. Patient records, CT and MRI scans, microbiology and histology as well as the postoperative clinical follow-up including endoscopic photo documentation were evaluated over a period of 5 years. All patients underwent endonasal surgery using endoscopic techniques. The microscopic was of additional help in a few cases with extended disease and multiple dehiscences of the skull base. Twenty-four patients had a chronic noninvasive of fungal sinusitis and 16 patients had a chronic invasive form. All these patients underwent endonasal surgery without external incision. The fungal disease was erradicated in 39 cases, and revision surgery was required in only one case in which involvement of the contralateral side was not initially detected. in two cases scar tissue in the middle meatus was later excised but without evidence of residual fungal disease. Only in 6 cases was antifungal chemotherapy required, where the disease had spread into surrounding tissue or the patient had severe symptoms. Endonasal microsurgical techniques are today the appropriate approach for managing chronic fungal sinus disease even in severe cases with radiologic evidence of expansion or invasion of surrounding tissue. Additional antifungal chemotherapy is only rarely indicated, specifically when the fungal disease invades surrounding tissue.

Fungal Infection of the Nasal Cavity and Paranasal Sinuses: Review of 26 Cases

Fungal infection of the nose and sinuses is an uncommon condition which is now being increasingly recognized. In this study we review clinicopathologic features in a series of 26 cases encountered at King Faisal Specialist Hospital and Research Centre over a five-year period. The cases were divided into four categories according to the following histopathologic features: allergic fungal sinusitis (11 cases), aspergilloma (one case), chronic indolent fungal sinusitis (five cases), and acute fulminant fungal sinusitis (nine cases). In the cases of allergic fungal sinusitis and aspergilloma, the fungal hyphae were limited to the sinus activity without any evidence of invasion. Invasion in the wall of the sinus, as well as the surrounding tissue, was noted in cases of chronic indolent fungal sinusitis and acute fulminant fungal sinusitis. All patients were treated surgically and those cases with evidence of tissue invasion on pathologic or radiologic examination were given antifungal therapy. The prognosis was excellent in the cases of allergic fungal sinusitis and aspergilloma. Most of the patients with acute fulminant fungal sinusitis died of uncontrolled fungus growth. In the cases of chronic indolent fungal sinusitis, all patients are still alive, but two patients had loss of vision due to fungal invasion. Fungal sinusitis with absence of tissue invasion is easily treated by surgery alone. However, in cases with tissue invasion, a combination of surgery with antifungal therapy may be successful. Acute fulminant fungal sinusitis, however, has a grave prognosis.

Allergic fungal sinusitis/polyposis.

In the last decade, the medical community has recognized allergic fungal sinusitis as an unique clinical entity strongly associated with nasal polyps. We will review the differential diagnosis, clinical features, diagnosis, treatment, and prognosis. Appropriate management requires distinguishing allergic fungal sinusitis from other forms of chronic fungal and bacterial sinusitis. Surgical treatment initially results in dramatic improvement, and oral steroids help maintain postoperative success. However, recurrent disease eventually prevails, leaving a glaring need for improved medical treatment.

Chronic fungal sinusitis in apparently normal hosts : RG Washburn, DW Kennedy, MG Begley, et al. Medicine 1988; 67:231–247

Chronic fungal sinusitis in apparently normal hosts : RG Washburn, DW Kennedy, MG Begley, et al. Medicine 1988; 67:231–247