MarioF.Romagnoli-1993The literature does not seem to support any increased incidence of nasal or paranasal colonization or infection with fungi, although we have recently seen a healthy, immunocompetent man who presented with diplopia and sphenoid mass lesion.

A. T. Henrici - 1939

In man and mammals fungal infections are so rare as to be of little practical importance

FUNGAL SINUSITIS

Dr. Ajay George

Goals of today’s class TO GET ATTENDANCE. To understand the pathogenesis of fungal

sinusitis. To know about the causative agents. To know the principles of treatment.

Predisposing Factors:

•Uncontrolled diabetics.

•Chronic renal failure.

•Immuno compromised patients.

HIV

Leukaemias

Drugs

Chronic debilitating illness.

Conidiobolus coronatus(Rhinophycomycosis)

Cases seen in Central Africa, Brazil, West Indies.

Presents as polyps/ granulomas. Lesions spread submucosally. Treatment is removal of mass & amphotericin.

Rhinocerebral phycomycosis

Caused by Rhizopus oryzae, Mucor javanicus, Mucor circinelloides, Absidia corymbitera.

Usually a saprophyte. Marked affinity for blood vessels. Involves Nose, PNS, Orbit, Brain. Disease is confirmed by biopsy. Local drainage & debridement & Amphotericin

Aspergillosis

Caused by A. fumigatus, A. niger, A. flavus. Causes all forms of fungal sinusitis. Diagnosis is from fresh scrappings, Treatment depends on manifestation.

Blastomycosis

Caused by thermally diamorphic fungus Blastomyces dermatidis.

Common in North America – Ohio & Mississippi river valley areas.

Confirmation by special staining and serology. It is rarely fatal. Treatment depends on severity.

Cryptococcosis

Caused by Cryptococcus neoformans. Found in avian excreta. Predeliction for lung and brain. Usually completely treatable.

Actinomycosis

Actinomyces israelii is pathogenic for humans. Trauma predisposes for pathogenicity. Treatment is high dose penicillin.

Candidiasis

Caused by Candida albicans. Presents as small, discrete, pearly or dirty white

patches on red moist mucous membrane which can be easily removed without bleeding.

Treatment is by local application of 1% aqueous gentian violet or nystation.

Histoplasmosis

Caused by Histoplasma capsulatum. Common in central USA. Diagnosis is by biopsy and histoplasmin skin

test. Treatment is by amphotericin.

Sporotrichosis

Caused by Sporothrix schenckii. Infection of mucosa is usually by implantation. Treatment is by iodides or amphotericin.

FULMINANT FUNGAL SINUSITIS

Clinical Course :Acute Host :Immunocomprised Pathology :Tissue Invasion Organisms :Aspergillus, Mucor Sinus Involvement :Single or multiple Treatment :Radical

debridement&Anti-

fungal therapy

INDOLENT FUNGAL SINUSITIS Clinical Course :Chronic Host :Immunocompetent Pathology :Granuloma Organisms :Aspergillus,

Dematiaceous fungi Sinus Involvement :Single or multiple Treatment :Radical

debridement&Anti-

fungal therapy SOS

MYCETOMA

Clinical Course :Chronic Host :Immunocompetent Pathology :Fungal ball Organisms :Aspergillus Sinus Involvement :Single Treatment :Debridement&

Aeration

ALLERGIC FUNGAL SINUSITIS

Clinical Course : Chronic Host : Atopic Pathology : Allergic mucin Organisms : Aspergillus,

Dematiaceous fungi Sinus Involvement : Multiple Treatment : Debridement,

Steroids& Immunotherapy

DIAGNOSTIC CRITERIAdeShazo Criteria (1995) Typical radiographic picture of sinusitis Macroscopic/histopathological demonstration of

allergic mucin Positive fungal stain/culture from surgery specimen No immunocompromise No evidence of tissue invasion

Bent & Kuhn Modification Positive skin tests to fungal antigens

ETIOLOGYAge : Young adultsGender : No marked trendsEnvironment : Moist & dustyCausative Agents :

Mainly dematiaceous fungi like Bipolaris, Curvularia, Exserohilum, Alternaria, Drechslera, Helminthosporium, and Fusarium,

Sometimes aspergillus

Atopic host Exposed to fungi

Type I&III Hypersensitivity

reactions

Proliferation of fungi Sinusitis and ostia block

Production of allergic mucin

PATHOGENESIS Polyposis and bony expansion

PRESENTING COMPLAINTS

Nasal ObstructionAllergic RhinitisPurulent RhinorrhoeaPost Nasal DripHeadacheFacial DeformityLoss of Vision

EXAMINATION FINDINGS

Intranasal inflammationPolyposisFacial Dysmorphism

Proptosis

Telecanthus

Malar flattening

Optic Nerve Compression

SPECIFIC INVESTIGATIONS

Serum Total IgEFungal Specific IgE, IgG, IgMSkin TestingRadioallergosorbent TestC T ScanHistopathology

TREATMENT

SurgeryCorticosteroidsImmunotherapyAnti-fungal agents

TAKE HOME MESSAGE

Fungal infestations of paranasal sinuses are relatively common

Even immunocompetent persons can get affected High degree of suspicion is necessary for diagnosis CT Scan, fungal serology and proper

microbiological study are very important for diagnosis

Standard therapy protocol with long term follow-up is necessary for good cure rates

FEEDBACK

Q.1 Did you get to learn anything new today which you can recollect ?

Q.2 Was information given more than necessary?

Q.3 Rate the lecture on a scale of 0 – 10.

Q.4 Any other comments or suggestions.

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