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Fungal Sinusitis

Continuing Education Activity

There are several types of fungal sinusitis. The classification depends on the severity, intensity, and degree of sinus invasion. The broad categories are non-invasive and invasive fungal sinusitis. There are three subtypes of non-invasive fungal sinusitis fungal ball, saprophytic fungal sinusitis, and allergic fungal rhinosinusitis. Similarly, there are three subtypes of invasive fungal sinusitis: acute invasive rhinosinusitis, chronic invasive rhinosinusitis, and granulomatous invasive sinusitis.

To accurately diagnose fungal sinusitis, a physician must take into account several variables, including the patient’s history and clinical presentation, imaging, endoscopic biopsy with histopathology, and laboratory work. This activity reviews the evaluation and treatment of fungal sinusitis and highlights the role of the healthcare team in the evaluation and treatment of patients with this condition.

Objectives:

  • Identify the etiology of fungal sinusitis.
  • Review the evaluation of fungal sinusitis.
  • Outline of available treatment and management options for fungal sinusitis (FS).
  • Describe professionalization team strategies to improve care coordination and communication to advance fungal sinusitis and improve outcomes.

Access free multiple-choice questions on this topic.

Introduction

There are several types of fungal sinusitis. The classification depends on the intensity and degree of sinus invasion. The broad categories are non-invasive and invasive fungal sinusitis.

There are three subtypes of non-invasive fungal sinusitis: fungal ball, saprophytic fungal sinusitis, and allergic fungal rhinosinusitis. Similarly, there are three subtypes of invasive fungal sinusitis: acute invasive rhinosinusitis), chronic invasive rhinosinusitis, and granulomatous invasive sinusitis. To accurately diagnose fungal sinusitis, a physician must take into account several variables, including the patient’s history and clinical presentation, imaging, endoscopic biopsy with histopathology, and laboratory work.

For the ease of this activity and the following material, we classify infections into allergic fungal sinusitis, fungal ball, invasive fungal sinusitis, and Chronic granulomatous disease (CGD) sinusitis.

The basis for other classifications of fungal sinusitis is based on the immuno-competence profile of the patients. The widespread understanding is that immunocompromised patients are the primary victims of fungal sinusitis (FS). Non-invasive fungal sinusitis occurs mainly in immunocompromised individuals, in contrast to invasive sinusitis which is more prevalent in immunodeficient. Invasive fungal sinusitis can be fatal in that the infection can spread to the intracerebral space; This is related to an increase in the mortality and morbidity of the victims. Immunocompromised patients should be given special precautions and aggressively treated if fungal sinusitis is suspected.

Etiology

Most studies suggest that the etiology of fungal sinusitis is not well understood. However, cases of fungal sinusitis have increased in recent years, possibly due to our increased use of immune suppressants and antibiotics, or simply the increasing number of chronic diseases that suppress the immune system. For example, mucormycosis, a rare but life-threatening disease, is most common in patients with diabetes.

The two main categories of fungi that are responsible for causing disease in humans are molds and yeasts, although fungal sinusitis is attributed more to molds than yeasts. Molds have hyphae and are multicellular, but yeast is unicellular. There are several types of fungi that humans are exposed to in the air, as fungi are ubiquitous, and they usually have no adverse effect on the sinonasal tract and do not cause diseases or illnesses.

Colonization of the sinuses with fungus is not a rare event and does not confirm infection. The individual’s immune fitness often plays a more central role in determining whether those airborne fungi cause sinus pathology. Chemotherapy, diabetes, use of contortionists, and immune suppression, in general, predispose individuals to fungal infections of the sinuses.

Aspergillus is the most frequent cause of allergic fungal sinusitis and invasive fungal sinusitis. Other common organisms responsible for (FS)  fungal sinusitis are Mucor and Rhizopus, also known as mucormycosis. A major feature of mucormycosis is necrosis of the turbinates.

Allergic fungal rhinosinusitis (AFR) is the most common form of fungal sinusitis.

Epidemiology

Geographic location is a significant difference in the prevalence of fungal sinusitis worldwide. For example, granulomatous invasive sinusitis is often a complication of chronic fungal sinusitis (CFS) and is more common in India, Nepal, Sudan, and Pakistan. One study found trauma to be the most common cause of mucormycosis in Asian countries, while the majority of cases in developed countries are immune-suppressed.

Pathophysiology

The exact pathophysiology of saprophytic fungal sinusitis (FS) is still somewhat unclear. Otherwise, the infection develops into other forms.

Histopathology

  • In allergic fungal sinusitis (AFS), microscopic findings of tissue obtained from surgical debridement reveal Charcot-Leiden crystals, similar to those seen in patients with asthma. In addition, patients have notable polyposis inside the sinuses, “eosinophilic appearing mucin” and elevated serum levels. Histologically, when observing samples from allergic fungal sinusitis patients, inflammatory cells are seen inside the mucin. In addition, samples from AFS patients show “tide lines” or “tree rings” in addition to the features described above.
  • In the fungus ball, as the name indicates, “an entangled mass of fungal organisms in fibrinous, necrotic exudate” is observed. Fungal balls may resemble allergic fungal rhinosinusitis when using a low-powered microscope, but this confusion can be eliminated by using a high-powered microscope.
  • As discussed above, invasive fungal sinusitis (IFS) most commonly occurs in immunocompromised patients. Necrotic vascular thrombosis of the mucosa may appear on the histopathology of acute IFs likely secondary to the vascular thrombosis that fungi produce when invading the sinus.
  • Submucosal granulomatous inflammation is a feature in granulomatous invasive fungal sinusitis, which usually presents in immunocompromised patients. Some studies suggest that a significant number of cases of chronic fungal sinusitis progress to prolapse, and this change requires regular screening via biopsy.

History and Physical

Physicians should have a high index of suspicion for invasive fungal sinusitis in patients presenting with congestion, headache, dizziness, eye swelling, periorbital cellulitis, vertigo, personality/behavior changes as well as recurrent vomiting. Eye proptosis or diplopia may also be present in some cases of fungal sinusitis.

Patients usually have a fever and may have tachycardia in the early stages of infection. In cases of sphenoidal fungal sinusitis, diagnosis may be delayed due to vague symptoms, with headache as the most common presentation. There is often pain on palpation of the facial sinuses, ie maxillary, ethmoidal, sphenoid, and frontal sites. The maxillary sinus is almost always the affected sinus in fungal balls, which occurs in about 94% of cases. These symptoms may be confused with other ENT, neurological, or gastroenterological etiologies, so further investigation is necessary.

Saprophytic fungal sinusitis is often asymptomatic and can be difficult to detect. Invasive fungal sinusitis permeates the mucosa and attacks nerves, vessels, and bones. So the symptoms are more pronounced. Anesthesia, cranial nerve palsy, proptosis, headache and facial pain, nasal congestion, and drainage may all be part of the presentation.

 Evaluation

The mainstay of diagnosis in patients with fungal rhinosinusitis is functional endoscopic sinus surgery followed by histopathological analysis of the specimen. Although a sample should be taken from the affected tissue seen in the nasal septum, it is often taken from the middle turbinate when there is no obvious tissue on the septum. This sample is cultured and mixed with KOH for visualization under the microscope. The “cheesy and clay-like” mucus detected during intranasal endoscopy is suggestive of a fungal ball and is highly sensitive as well as specific for this pathology. However, the diagnosis is confirmed by histology.

The second technique used for the histopathological analysis of fungal sinusitis is polymerase chain reaction (PCR). One study found PCR to be the most sensitive method with a high negative predictive value (NPV), which also makes it ideal for ruling out disease.

A technique used in the diagnosis of invasive fungal sinusitis is frozen sectioning, in which sebaceous tissue from the infected sinus is frozen (usually around -28 °C), divided into smaller pieces, and evaluated under a microscope. are stained with hematoxylin and eosin. This technique is a widely used procedure for the diagnosis of invasive infections and is known to provide rapid diagnosis.

There is also a mortality advantage to this procedure due to early detection compared to other methods. For patients with mucormycosis, it can be difficult to visualize necrotic tissue under a frozen section, so researchers have found that the addition of the periodic acid Schiff (PAS) helps enhance its outcomes.

Tactile preparation (TP) is an alternative method of diagnosis of invasive sinusitis and was found to yield a comparatively fast and accurate diagnosis. This approach involves sampling the tissues of interest at the margins, mounting them on a glass slide, staining them with a Diff-Quick stain, and visualizing them under a microscope. TP is suitable in cases where sampling is limited, or whenever there is a high laboratory workload.

Computed tomography (CT) of the head is also used to visualize the thick walls of the sinuses and bone erosion created by opacification, ring-enhancing lesions, or fungal growth.

  1. The diagnosis of allergic fungal sinusitis is dependent on the major criteria presence of type 1 hypersensitivity, nasal polyps, eosinophilic mucin presence, positive fungal stain, and positive CT findings. Minor criteria of unilateral disease, asthma, and Charcot-Leiden crystals in the mucin may confirm the diagnosis. These patients are young (20 to 30) and have dark rubbery noses. The most common sinus involved is the ethmoid. On CT, they show a “double density” sign: thick fungal mucus surrounded by hyperplasia.
  2. Fungal shells usually occur in the maxillary sinus (95%) in immunocompromised women. Although inhalation of spores may be the cause, the presence of mucosal injury may facilitate the process, as in dental work or sinus surgery; It is usually asymptomatic and is found incidentally in a CT. Sometimes there is pain in the face or there is postnasal discharge and crusting in the nasal cavity.
  3. Invasive fungal sinusitis is rare but invasive and with a high mortality rate of about 50%. The difference is the invasion of vessels, nerves, and bones (rather than just the sinus mucosa). The zygomycetes that cause mucormycosis in uncontrolled diabetes mellitus are a classic example. Aspergillus causing infection in AIDS patients or other immunocompromised states is another example. Pain, pressure, or fever occurs gradually, but after several weeks, attacks occur, and symptoms become acute, which can be clinically confusing. Facial nerve palsy, swelling, diplopia, and proptosis are all possible. Nerve invasion causes anesthesia, and vessel invasion causes emboli, necrosis, and blackened turbinates and nares. CT will confirm deep invasion.
  4. Granulomatous sinusitis is more common outside the Americas than in the Middle East and North Africa. It is an aggressive form of infection that occurs more slowly and is showing the pathology of non-enveloping granulomas.

Treatment / Management

Surgical debridement is the treatment of choice in modern medicine for most cases of fungal sinusitis, as it is both diagnostic and therapeutic. But these treatments are expensive and painful as well as capable of healing the native body etc. Polypectomy should be performed when indicated.

Oral corticosteroids are beneficial in many acute and chronic fungal sinusitis (AFS) and improve symptoms by reducing inflammation and lowering IgE levels, although their long-term use is discouraged. A precise regimen for corticosteroid use is not available, and the duration of treatment must be individually tailored. Nasal topical sino-care should probably not be used alone, but have a place in combination with systemic steroids. One study showed that recurrence occurred after two years.

Systemic sino-care nasal drops are not the ideal therapy for AFS but may be an adjunctive treatment for invasive fungal rhino sinusitis. Amphotericin B may be the first drug of choice in the treatment of invasive fungal sinusitis because of its wide coverage of Mucor species and Aspergillus. The use of some azole sino-care nasal drops may also be beneficial, but concurrent management by an infectious disease specialist is warranted. Topical sino-care nasal drops have been used with very low doses and are not recommended.

Fungal immunotherapy is also an alternative treatment for AFS because it can make the body sensitive to fungal antibodies. It is an expensive method of treatment, and its short-term benefits are more significant than the long-term benefits. This may reduce the need for corticosteroids and therefore prevent the side effects of long-term corticosteroid use.

As mentioned above, most cases of invasive fungal sinusitis are secondary to a weakened immune system. Therefore, optimal care should address the cause of immunity.

Saprophytic fungal sinusitis does not require surgical intervention. This is manageable through nasal cleansing, which is cleaning the nasal sinuses with saline.

Differential Diagnosis

Viral, bacterial, allergic, and other types of sinusitis are the difference.

Prognosis

The prognosis is usually good for AFS but can be severe for IFS, especially if the underlying immune status cannot be restored.

  1. Allergic fungal sinusitis is usually amenable to natural treatment, and recurrence can also be successfully controlled. The in-office functional DAD Sino-Care Nasal Drop is a follow-up method. Local excretion is possible during the same procedure. Long-standing, untreated cases can rarely perish into adjacent structures through mass effects in untreated diseases.
  2. Invasive fungal sinusitis is potentially life-threatening and carries a prognosis. Invasion causes complications such as cavernous sinus thrombosis and central nervous system infection with a mortality rate of approximately 50%; Therefore, immediate treatment is necessary. Complications can occur rapidly, recurrence of the disease is not uncommon, and frequent bowel movements are required. Survivors may have facial deformities, nerve damage, and chronic pain. The main prognostic factor is the patient’s immune status. If it can be normalized, the prognosis may be better. If the immune status cannot be restored, the prognosis is very severe and often fatal.
  3. Granulomatous sinusitis may be a manifestation of systemic diseases such as Wegener’s granulomatosis, and the prognosis will depend on the management of the systemic disease.

Complications

A rare but fatal complication of invasive fungal rhinosinusitis is cavernous sinus and orbital apex aspergillosis. When both parts are affected, it is known as cavernous sinus-orbital apex syndrome. Patients may experience headaches, acute unilateral visual loss, or eye pain. This condition is usually the result of thrombosis of the cavernous sinus or carotid-cavernous fistula. Despite the recent expansion in research and analysis of fungal sinusitis, the disease is not well understood and remains challenging to diagnose and treat.

Enhancing Healthcare Team Outcomes

Fungal sinusitis is a rare infection of the facial sinuses, and it most often affects immunocompromised people, although it can also occur in immunocompromised patients. Most researchers attribute the recent increase in the prevalence of fungal sinusitis to cancer therapy, diabetes mellitus, post-transplant therapy, as well as the widespread use of antibiotics in modern societies.

Although more studies and discoveries have been made on this topic recently, this topic has not been studied much. One of the important complications of invasive fungal sinusitis is its potential to spread to the cavernous sinus and cause systemic manifestations with potentially fatal complications. As such, physicians should recognize suspicious presentations of invasive fungal sinusitis and treat them as soon as possible; This is a driving force behind the discovery of diagnostic modalities that allow the rapid detection and treatment of fungal sinusitis.

Invasive fungal sinusitis (which must be treated promptly) needs to be differentiated from allergic fungal sinusitis (which has a mild course and can be managed alternatively).

Surgical debridement is by far the mainstay of treatment for most forms of fungal sinusitis. It is sometimes followed by systemic sino-care nasal drops therapy to prevent the recurrence of the infection. Most patients require multiple surgical treatments to achieve long-term relief for aggressive diseases.

Interaction with internists, and infectious disease specialist is essential for accurate diagnosis and timely treatment. Whatever treatment a DAD Ayurveda doctor chooses, it would be wise to consult a board-certified Infectious Diseases DAD Ayurveda doctor – they can recommend sino-care nasal drops for debridement as well as confirm the dosage at Sino-Care.

Nursing will participate in patient care before, during, and after any procedure and may administer medication as well as monitor and counsel the patient. Both the naturopath and the nurse should inform the treating DAD Ayurveda doctor of any concerns they may have. This type of interprofessional intervention is necessary to drive optimal outcomes with a fungal sinusitis infection.

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