Fungal Rhinosinusitis Research Articles

Invasive Fungal Rhinosinusitis With Intracranial and Orbital Involvement: A Case Report

Invasive Fungal Rhinosinusitis With Intracranial and Orbital Involvement: A Case Report

Prostaglandin E Receptor 2 (EP2) Dysregulation in Allergic Fungal Rhinosinusitis Nasal Polyp Epithelium.

Allergic fungal rhinosinusitis (AFRS) is an eosinophilic subtype of chronic rhinosinusitis with nasal polyposis (CRSwNP). This study aimed to investigate the transcriptome of AFRS nasal polyp epithelium. Sinonasal epithelial cells were harvested from healthy nasal mucosa and polyp tissue collected from participants undergoing elective sinonasal surgery. Primary epithelial cells were subsequently grown in air/liquid interface and subjected to RNA-seq analysis, RT-qPCR, immunoblotting, and immunostaining. A total of 19 genes were differentially expressed between healthy and AFRS sample epithelium. The second top candidate gene, ranked by adjusted p-value, was prostaglandin E receptor 2 (PTGER2). The upregulation of PTGER2 was confirmed by RT-qPCR and immunoblot. The presence of the EP2 receptor, encoded by the PTGER2 gene, was confirmed by immunocytochemistry. PTGER2 is a potential novel therapeutic target for AFRS. EP2 dysregulation is associated with aspirin-exacerbated respiratory disease, potentially giving insight into common mechanisms of disease in severe CRSwNP. NA Laryngoscope, 2024.

The evaluation of therapeutic outcomes of biologics in allergic fungal rhinosinusitis: a systematic review and meta-analysis.

Allergic fungal rhinosinusitis (AFRS) is a localized inflammatory, hypersensitivity reaction affecting the nasal cavity and its sinuses secondary to fungal colonization. The burden of surgical revisions and recurrence rates in this disease led to a recent hypothesized advancement in the medical management being experimented, which is the use of biologics. Therefore, this systematic review analyzed nine articles to highlight the significance of biologics in the management of AFRS through a comprehensive strategy, as seen in Supplementary Methods Section (1-9).

Clearing the Air: Acute Invasive Fungal Rhinosinusitis in Hematologic Cancer Patients.

Air quality has been shown to impact the rates of fungal infection of the airway, causing diseases such as acute invasive fungal rhinosinusitis (AIFRS), particularly in immunocompromised patients. We theorize that patients with hematologic malignancies in units with aging air handling units (AHUs) have a higher attack rate of AIFRS. Retrospective chart review identified patients with hematologic malignancy and AIFRS in two distinct and equal time periods between 2013 and 2022, representing the presence of aging AHUs and new AHUs, respectively. Cubic feet per minute (CFM) air flows, AIFRS attack rates, and clinical data were compared between the two groups and statistical analyses performed. The older AHUs produce air flow of 27,610 CFM and the newer AHUs produce air flow of 80,000 CFM. There were 18 patients with air supplied by older AHUs and 7 patients with air supplied by new AHUs who developed AIFRS. There was a significantly higher AIFRS attack rate for patients supplied by the older AHUs compared with patients supplied by newer AHUs (p = 0.033). The patients supplied by the older AHUs tended to be younger. The white blood cell counts, absolute neutrophil counts, and the mean time to diagnosis did not differ between the two groups. To our knowledge, this is the first study to examine AIFRS in immunocompromised patients' inpatient environment. Further research should explore whether higher CFM AHUs can decrease this disease among our most vulnerable patients. 3 Laryngoscope, 134:4466-4470, 2024.

Abducens nerve palsy secondary to allergic fungal sinusitis

Abstract Allergic fungal rhinosinusitis (AFRS) stands out as the predominant form of fungal sinusitis, primarily attributable to a hypersensitive response to fungal invasion. AFRS Characterized by symptoms of rhinosinusitis. The expanding mass in the disease leads to bony restructuring and implicating adjacent anatomical structures. AFRS may extend beyond the sinus cavities, leading to compression of nearby structures like the orbit, optic and abducens nerves which leads to many complications such as nerve palsies and proptosis. Diagnosis of AFRS typically necessitates radiographic assessment initially, with histopathological examination serving as the confirmatory modality. The management of AFRS typically entails a multifaceted approach integrating surgical intervention alongside medical therapy. This case report illustrates a distinctive manifestation of abducens nerve palsy secondary to allergic fungal sinusitis which had dramatic improvement and resolution of the diplopia after the Endoscopic sinus surgery. Steroids and nasal saline irrigation have been prescribed post operatively to prevent the recurrence.

Fungal disease incidence and prevalence in Iraq – Preliminary estimates

BackgroundThe surveillance of serious and superficial skin fungal infections in Iraq has not been conducted. Limited information exists on their incidence and prevalence. ObjectivesThis study aimed to analyze, compute and estimate the prevalence and burden of fungal infections, as no previous data is available and no studies has been attempted in Iraq. MethodsIn the present study the data were collected and reviewed from published data on epidemiology of fungal infections nationally, internationally, from unpublished postgraduate master and PhD theses, hospital records and private clinic records. External sources of data from other countries were used for diseases which lacked sufficient local data. ResultsWe estimated 985,628 annual serious infections comprising of 2.26 % of the total population. When including superficial fungal infections group of the skin, this rises to 2,075,113 infections at 4.76 % of the total population. The most common serious and skin infections were recurrent Candida vaginitis, fungal rhinosinusitis and tinea capitis comprising 61.5 %, 21.8 %, and 22.4 % of all infections although the total incidence of superficial fungal infections was also high at 1,071,485. Respiratory fungal disease is also common comprising 14.0 % of infections. We predicted the following annual burden per 100,000; oral candidiasis at 247.9, esophageal candidiasis at 6.04, candidemia at 5.0, Candida peritonitis at 0.75, recurrent Candida vaginitis at 5461, allergic bronchopulmonary aspergillosis at 35, severe asthma with fungal sensitisation at 46, invasive aspergillosis at 7.9, chronic pulmonary aspergillosis at 11.7, chronic fungal rhinosinusitis at 496, mucormycosis at 0.99, fungal keratitis at 14.0, and total dermatophytosis at 1631, the most severe being tinea capitis at 366. Many of these estimates were made with data sourced from other nations, so additional data from Iraq is required to validate or modify these estimates. ConclusionRecurrent Candida vaginitis, fungal rhinosinusitis, and tinea capitis are considered to be the most frequent fungal diseases present in Iraq.

Radiographic Variants Associated With Allergic Fungal Rhinosinusitis: Key Differences for Pre-Operative Planning.

Allergic fungal rhinosinusitis (AFRS) often results in expansion of disease beyond the paranasal sinuses, which may put important structures, such as the anterior ethmoid artery (AEA) or lateral lamella of the cribiform, at risk of injury during endoscopic sinus surgery (ESS). This study aims to compare the AEA to skull base (AEA-SB) length in patients with AFRS versus chronic rhinosinusitis with nasal polyps (CRSwNP), as well as additional anatomic variants. A single institutional retrospective chart review of patients undergoing ESS for AFRS and CRSwNP was performed. AEA-SB length were compared between the 2 groups. Other anatomic variants, including Keros measurement and presence of supraorbital ethmoid air cells (SOEC), concha bullosa (CB), sphenoethmoidal, and infraorbital ethmoid cells were measured and compared between the 2 groups. Twenty-one patients were included in each cohort. The AFRS group was younger in age (P = .015) and had a significantly longer AEA-SB length (P = .014) compared to the CRSwNP group. No significant differences were observed between the 2 groups regarding Keros measurement, presence of concha bullosa, infraorbital ethmoid, sphenoethmoidal, or SOEC. No association was seen between AEA-SB length and Keros class in either group. AFRS harbors anatomical differences when compared to CRSwNP, with the former associated with a longer AEA-SB length. This key difference should be considered in preoperative planning to prevent injury to the AEA in patients undergoing ESS for AFRS.

Evaluation of metagenomic next-generation sequencing (mNGS) combined with quantitative PCR: cutting-edge methods for rapid diagnosis of non-invasive fungal rhinosinusitis.

Fungal rhinosinusitis is a significant and growing health concern in arid regions, with an increasing incidence over recent decades. Without timely and appropriate management, it can lead to severe complications, including potential intracranial spread. This study aims to establish efficient and rapid diagnostics for non-invasive fungal rhinosinusitis (FRS), addressing the challenge of its difficult-to-culture diagnosis. Twenty-eight patients suspected of FRS were studied using endoscopic sinus surgery to obtain tissue samples for histopathology, direct microscopy, fungal culture, quantitative PCR (qPCR) and metagenomic next-generation sequencing (mNGS) detection. A patented qPCR targeting prevalent Aspergillus species was evaluated. The patient cohort had a male-to-female ratio of 9:14, with disease duration up to 50 years. Histopathologically, 23 out of 28 cases were positive. Fungal culture exhibited a sensitivity of 21.74%, with one false positive. qPCR and mNGS showed 100% sensitivity and specificity, with a 100% consistency rate for identification at the species level (23/23), and potential detection of cases with co-infections. The most common pathogen was A. flavus, followed by A. fumigatus and A. niger. Two cases involved mixed infections of A. fumigatus and A. flavus. qPCR and mNGS proved effective in rapidly identifying fungi from fresh sinus tissue that are challenging to culture, surpassing conventional methods. However, further evaluation and optimization with a larger cohort of patients are necessary. Histopathology is still recommended to confirm the clinical significance of the detected fungal species.

Invasive Fungal Rhinosinusitis: The First Histopathological Study in Vietnam.

Invasive fungal rhinosinusitis (IRFS) is a rare but highly fatal disease. The two primary groups of pathogens, Mucorales and Aspergillus, require different treatments and have distinct prognoses. This study aimed to analyze the histopathological features of IFRS. We conducted a retrospective study involving 57 IFRS cases. Demographic and comorbid characteristics were obtained from clinical records. Two pathologists independently examined the histopathological features using H&E, PAS, and GMS-stained slides. Fungal groups were identified with PCR under the guidance of histopathology. The mean age of IFRS was 58.9 ± 13.4. The male-to-female ratio was 1.4:1. 100% of cases had diabetes comorbidity. Mucorales, Aspergillus, and other fungi were found in 61.4%, 33.3%, and 5.3% of cases, respectively. No Aspergillus and Mucorales co-infections were detected. Histopathology and PCR results were strongly concordant in classifying pathogens (Cohen's kappa = 84.2%, 95% CI 60.1% - 100%, p < 0.001). Mucormycosis exhibited higher rates of extensive necrosis and vascular invasion, and lower rates of pigment and spore presence than the non-Mucormycosis group (p < 0.001, p = 0.01, p = 0.02, p = 0.03, respectively). Extensive necrosis and vascular invasion were statistically significantly correlative (OR = 13.03, 95% CI 2.62-64.75, p = 0.002). IFRS predominantly affects older adults and males. Histopathology is a reliable method for differentiating between Mucorales and Aspergillus. When extensive necrosis is detected, it is critical to investigate for vascular invasion carefully. The vascular invasion, degree of necrosis, pigments, and spores are valuable factors for distinguishing fungal agents of IFRS.

High M2/M1 Macrophage Ratio Observed in Nasal Polyps Formed in Allergic Fungal Rhinosinusitis.

Allergic fungal rhinosinusitis (AFRS) shares similarities with eosinophilic chronic rhinosinusitis (ECRS), both characterized by intractable nasal polyps. The key distinction lies in the presence of fungal infection within the nasal cavity. While ECRS nasal polyps are known for significant infiltration of M2 macrophages and eosinophils, as well as an increase in high endothelial venule (HEV)-like vessels, these features are less commonly reported in AFRS. This study compared clinicopathological findings between AFRS (n=10), ECRS (n=12), and non-ECRS (n=10) patients' nasal polyps using immunohistochemical analysis for CD163 and CD68 to assess the M2/M1 macrophage ratio, and peripheral lymph node addressin (PNAd) and CD34 to evaluate the proportion of HEV-like vessels. AFRS showed a significantly higher number of CD163-positive M2 macrophages and an increased M2/M1 ratio compared with ECRS. However, the percentage of HEV-like vessels and the number of eosinophils infiltrating the nasal polyps were similar in both AFRS and ECRS. The observed increase in M2 macrophages in AFRS nasal polyps is presumed to be induced by fungal infection in the nasal cavity, in comparison with ECRS. These results highlight the distinctive immunological profiles of AFRS and ECRS, emphasizing the role of macrophage polarization in their pathogenesis.

How Common is Allergic Fungal Rhinosinusitis in Chronic Rhinosinusitis Patient - A Retrospective Institutional Study

How Common is Allergic Fungal Rhinosinusitis in Chronic Rhinosinusitis Patient - A Retrospective Institutional Study

Chronic Invasive Fungal Sinusitis Mimicking Malignancy Post-Radiotherapy: A Case Report.

Invasive fungal sinusitis is a life-threatening form of fungal rhinosinusitis. Due to the aggressive clinical presentation and radiological appearance, there is diagnostic difficulty in differentiating invasive fungal sinusitis from a malignant process. This is even more challenging in oncological patients who have undergone previous head and neck radiotherapy, due to possibility of a recurrence of primary malignancy and radiation-induced neoplasms. We report a rare case of invasive fungal sinusitis mimicking a malignancy in a post-radiotherapy patient.Our patient was a 68-year-old male, 25-years post-radiotherapy for nasopharyngeal carcinoma. He presented with a 3-month history of purulent sputum and right facial paraesthesia. Magnetic resonance imaging showed an irregular destructive enhancing mass of the greater wing of right sphenoid and pterygoid bone with extensive extension into nearby structures. In view of extensive local and bony invasion, and a history of radiotherapy, initial suspicions were that of primary malignancy, specifically radiation-induced sarcoma, and recurrence of nasopharyngeal carcinoma. He underwent transpterygoid biopsy of the lesion, and histopathology demonstrated Aspergillus species, with no malignancy identified.Our report highlights the diagnostic difficulties in the post-radiotherapy cancer patient presenting with symptoms suggestive of aggressive sino-nasal disease. Invasive fungal sinusitis closely mimics the clinical and radiological findings of several neoplastic processes. We discuss the clinical and radiological characteristics of pathologies that may mimic invasive fungal sinusitis. Histological examination remains the gold standard for diagnosis, and early fungal staining is crucial. Furthermore, one should not presume the initial histopathological diagnosis to be confirmatory of isolated fungal disease. Repeat radiological investigations for disease resolution and histopathologic re-evaluation if required should be performed, keeping in mind possibility of coexisting malignancy.

Surgical Intervention Outcome for Patients With Acute Vision Loss Due to Allergic Fungal Rhinosinusitis: A Systematic Review and Meta-Analysis.

Allergic fungal rhinosinusitis (AFRS) is a severe type of chronic rhinosinusitis (CRS) characterized by a high risk of acute vision loss resulting from the affection of optic nerves. This vision loss results from direct pressure upon the optic nerve by the sinus tissues and bone degradation. This is why early involvement of a professional is significant so as not to result in a permanent disability. This systematic review and meta-analysis will analyze the efficacy of surgical operations in enhancing visual outcomes in patients with acute vision loss due to AFRS. A systematic search was carried out based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using PubMed, Embase, Cochrane Library, and Scopus with the keywords "acute vision loss," "allergic fungal rhinosinusitis," and "surgical intervention." The studies included patients who developed AFRS-related acute vision loss, those assessing the outcomes of the surgical interventions, and those published in English. Two separate researchers extracted data and conducted quality assessments. The data synthesis process employed the R studio software (Posit, Boston, MA). The identified studies for the review constituted 12 and involved 320 patients. The mean pooled event rate regarding acute vision loss of AFRS patients was 33.1%. Ear, nose, and throat surgeries, including functional endoscopic sinus surgery (FESS) and optic nerve decompression, had a mean pooled success in vision recovery of 68%. Early treatment and utilization of other types of corticosteroids were utilized to enhance the results. Hence, early and proper surgery like FESS, optic nerve decompression, and corticosteroid treatment have better visual prognosis in AFRS patients. Standard early diagnosis and management guarantee the prevention of irreversible blindness, which stresses the need for an interdisciplinary approach and further studies.

A mini-update on chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is an inflammatory disorder of the paranasal sinuses and the nasal cavity lasting longer than 12 weeks. This disease is a common clinical syndrome with significant monetary burden due to the high costs of medical visits, diagnostic tests, medications, and surgical therapies. CRS without nasal polyposis (CRSsNP) is the most common subtype of CRS, accounting for about 70% of all patients. Other subtypes include CRS with nasal polyposis (CRSwNP) and allergic fungal rhinosinusitis (AFRS). CRSwNP has the worldwide prevalence of 2% to 4% and is often accompanied by type 2 inflammation and asthma as a comorbid condition. Pediatric chronic sinusitis is distinct from adult chronic sinusitis and is currently considered an infectious process, characterized by persistent inflammation representing an exaggerated immune response to an external stimulus. The medical and surgical management of CRS has been remarkably modified in the past two decades. The aim of this study was to present an update on CRS based on the recent years’ literature.

Impact of Biologics on Surgery in Chronic Rhinosinusitis with Polyps and Allergic Fungal Sinusitis.

To compare the efficacy of th2-targeted biologic medications (dupilumab, omalizumab, and mepolizumab) on absolute risk reduction (ARR) of functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) and allergic fungal rhinosinusitis (AFRS). The TriNetX Research Network database was queried for each mAb's market lifespan through March 2024. Adults with CRSwNP were propensity score matched against non-mAb controls based on age, sex, race, and asthma diagnosis. The primary outcome was rate of FESS, with secondary outcomes including inpatient admission, emergency department (ED) visit, and incidence of acute sinusitis. Subgroup analysis was performed for patients with AFRS. All mAbs decreased FESS risk (dupilumab, ARR 11.48%, 95% CI 9.82%-13.15%, p < 0.001; omalizumab, ARR 12.02%, 95% CI 4.36%-19.68%, p = 0.002; mepolizumab, ARR 10.32%, 95% CI 5.24%-15.40%, p < 0.001) in CRSwNP patients. Only dupilumab also reduced risk of inpatient admission (ARR 8.59%, 95% CI 7.04%-10.15%, p < 0.001), ED visit (ARR 5.94%, 95% CI 4.28%-7.61%, p < 0.001), and acute sinusitis (ARR 2.60%, 95% CI 1.09%-4.12%, p = 0.001). In AFRS patients, only dupilumab reduced the risk of all outcomes: FESS (ARR 6.97%, 95 CI 2.86%-11.09%, p = 0.001), inpatient admission (ARR 16.93%, 95% CI 11.30%-22.57%, p < 0.001), ED visit (ARR 13.15%, 95% CI 7.15%-19.14%, p < 0.001), and acute sinusitis (ARR 7.17%, 95% CI 2.18%-12.17%, p = 0.005). Although all mAbs reduced FESS risk in CRSwNP, only dupilumab reduced secondary outcomes as well. Similarly, only dupilumab improved all outcomes in AFRS patients. These data demonstrate the potential of mAbs in reducing disease burden and enhancing patient outcomes in CRSwNP and AFRS. NA Laryngoscope, 2024.

The accuracy of deep learning models for diagnosing maxillary fungal ball rhinosinusitis.

To assess the accuracy of deep learning models for the diagnosis of maxillary fungal ball rhinosinusitis (MFB) and to compare the accuracy, sensitivity, specificity, precision, and F1-score with a rhinologist. Data from 1539 adult chronic rhinosinusitis (CRS) patients who underwent paranasal sinus computed tomography (CT) were collected. The overall dataset consisted of 254 MFB cases and 1285 non-MFB cases. The CT images were constructed and labeled to form the deep learning models. Seventy percent of the images were used for training the deep-learning models, and 30% were used for testing. Whole image analysis and instance segmentation analysis were performed using three different architectures: MobileNetv3, ResNet50, and ResNet101 for whole image analysis, and YOLOv5X-SEG, YOLOv8X-SEG, and YOLOv9-C-SEG for instance segmentation analysis. The ROC curve was assessed. Accuracy, sensitivity (recall), specificity, precision, and F1-score were compared between the models and a rhinologist. Kappa agreement was evaluated. Whole image analysis showed lower precision, recall, and F1-score compared to instance segmentation. The models exhibited an area under the ROC curve of 0.86 for whole image analysis and 0.88 for instance segmentation. In the testing dataset for whole images, the MobileNet V3 model showed 81.00% accuracy, 47.40% sensitivity, 87.90% specificity, 66.80% precision, and a 67.20% F1 score. Instance segmentation yielded the best evaluation with YOLOv8X-SEG showing 94.10% accuracy, 85.90% sensitivity, 95.80% specificity, 88.90% precision, and an 89.80% F1-score. The rhinologist achieved 93.5% accuracy, 84.6% sensitivity, 95.3% specificity, 78.6% precision, and an 81.5% F1-score. Utilizing paranasal sinus CT imaging with enhanced localization and constructive instance segmentation in deep learning models can be the practical promising deep learning system in assisting physicians for diagnosing maxillary fungal ball.

Outcomes in Hematologic Malignancy Patients with Acute Invasive Fungal Rhinosinusitis

Outcomes in Hematologic Malignancy Patients with Acute Invasive Fungal Rhinosinusitis

Characterising the allergic fungal rhinosinusitis microenvironment using full-length 16S rRNA gene amplicon sequencing and fungal ITS sequencing.

Allergic fungal rhinosinusitis (AFRS) is a severe phenotype of chronic rhinosinusitis with nasal polyposis (CRSwNP), characterised by localised and exaggerated type 2 inflammation. While fungal antigenic stimulation of unregulated Th2-mediated inflammation is the core pathophysiological mechanism, the direct and synergistic role of bacteria in disease modification is a pervasive hypothesis. We set out to define the microenvironment of AFRS to elucidate virulent organisms that may be implicated in the pathophysiology of AFRS. We undertook a cross-sectional study of AFRS patients and non-fungal CRSwNP patients. Demographics, disease severity, culture and microbiome sequences were analysed. Multimodality microbiome sequencing included short-read next-generation sequencing (NGS) on the Illumina Miseq (16S rRNA and ITS) and full-length 16S rRNA sequencing on the Oxford Nanopore Technologies GridION (ONT). Thirty-two AFRS and 29 non-fungal CRSwNP patients (NF) were included in this study. Staphylococcus aureus was the dominant organism cultured and sequenced in both AFRS and NF groups (AFRS 27.54%; NF 18.04%; p = .07). Streptococcus pneumoniae (AFRS 12.31%; NF 0.98%; p = .03) and Haemophilus influenzae (AFRS 15.03%; NF 0.24%; p = .005) were significantly more abundant in AFRS. Bacterial diversity (Shannon's index) was considerably lower in AFRS relative to NF (AFRS 0.6; NF 1.0, p = .008). Aspergillus was the most cultured fungus in AFRS (10/32, 31.3%). The AFRS sequenced mycobiome was predominantly represented by Malassezia (43.6%), Curvularia (18.5%) and Aspergillus (16.8%), while the NF mycobiome was nearly exclusively Malassezia (84.2%) with an absence of Aspergillus or dematiaceous fungi. A low diversity, dysbiotic microenvironment dominated by Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae characterised the bacterial microbiome of AFRS, with a mycobiome abundant in Malassezia, Aspergillus and Curvularia. While Staphylococcus aureus has been previously implicated in AFRS through enterotoxin superantigen potential, Streptococcus pneumoniae and Haemophilus influenzae are novel findings that may represent alternate cross-kingdom pathophysiological mechanisms.

Chronic invasive fungal rhinosinusitis with septal perforation: a case report

Background: Chronic Invasive Fungal Rhinosinusitis (CIFRS) is a sub-entity of fungal rhinosinusitis, with the most common causes being Aspergillus and Mucor. Non-specific symptoms such as nasal obstruction, headaches, face pain, rhinorrhea, and epistaxis are frequently observed in patients with CIFRS. Extension to the nasal septal is a scarce case. This case report aims to present a rare case report of a 50-year-old female considered immunocompetent with chronic invasive fungal rhinosinusitis with septal perforation at our hospital who underwent Functional Endoscopic Sinus Surgery (FESS). Case Presentation: Fifty-year-old female was referred to the Otorhinolaryngology Department, Mangusada Regional Hospital, with a blocked nose, especially on the right side, with frequently purulent nasal discharge, headache, and she had a foul smell in the nose for about 5 years, then in the last few months, the symptoms became worse, and she frequently had bloody discharge and anosmia. The patient came to our hospital due to failure of previous medical therapy. She denied any history of underlying systemic disease, relevant trauma, and nasal surgery. A large polypoid mass with an obstructed right middle meatus was detected on nasal endoscopy. A dark-brown substance resembling clay was found in the right posterior nasal cavity, close to the posterior nasal septum. The same material was seen in the left posterior nasal cavity, close to the posterior nasal septum. Computed Tomography (CT)-scan demonstrated a soft tissue density in the right maxillary sinus. The density extended into the left nasal cavity through a septal defect. The patient was done surgically with FESS to restore the drainage of the nasal cavity and paranasal sinuses. It is crucial to remove all the debris and infected tissue altogether. After the surgery, the patient was given nasal irrigation therapy with physiological saline solution 2 times a day and the condition improved. Conclusion: Diagnosing invasive fungal rhinosinusitis can be challenging due to its non-specific clinical presentation. Awareness, early diagnosis, and intervention help prevent permanent complications.

Invasive fungal rhinosinusitis: current evidence and research opportunities.

To summarize the evidence surrounding diagnosis, treatment, prognosis, and surveillance of patients with acute invasive fungal sinusitis (AIFS) and discuss future research needs. New risk factors for AIFS such as COVID have been identified, and a new prognostic staging system has been developed. Most patients who develop AIFS are immunocompromised, with the majority having a history of diabetes or a hematologic malignancy. Unfortunately, there are not any highly sensitive and specific diagnostic tools. Therefore, a combination of signs and symptoms, imaging, endoscopy, biopsy, and labs should be used to diagnosis AIFS. Although surgery and systemic antifungals are known to improve outcomes, there is limited data on time to intervention, duration of antifungals, and surveillance patterns. There is also limited information on factors that can predict outcomes in AIFS patients. However, sensory/perceptual changes, prolonged neutropenia duration, and comorbidity burden may be associated with a poor prognosis.