Allergic fungal rhinosinusitis: diagnosis and management

PURPOSE OF REVIEW: The proper diagnosis and treatment of allergic fungal rhinosinusitis remain controversial. We discuss recent additions to the literature regarding diagnosis and treatment of this condition. RECENT FINDINGS: There is considerable overlap in the clinical features of allergic fungal rhinosinusitis and other forms of eosinophilic mucin chronic rhinosinusitis. Type 1 hypersensitivity and characteristic computed tomographic findings may have predictive value for a final diagnosis of allergic fungal rhinosinusitis, patients with which are more likely to have bony erosion than patients with other forms of chronic rhinosinusitis. The decreases in orbital volume associated with expansive allergic fungal rhinosinusitis disease may spontaneously improve after successful treatment. Most patients have detectable fungal-specific IgE in their so-called allergic mucin. Elevated levels of fungal-specific IgG3 are a consistent finding in patients with allergic fungal rhinosinusitis and eosinophilic mucin chronic rhinosinusitis. Antifungal treatment is still considered a treatment option, but further study is needed. SUMMARY: Type 1 hypersensitivity to fungal antigens helps to distinguish allergic fungal rhinosinusitis from other forms of eosinophilic mucin chronic rhinosinusitis. Bony erosion and orbital expansion giving rise to proptosis are prominent features of allergic fungal rhinosinusitis. Advances in medical treatment will require prospective and controlled trials.     

The role of fungi in the etiology of chronic rhinosinusitis: a prospective study

OBJECTIVES: Allergic fungal sinusitis (AFS) may represent an endpoint in a spectrum of sinonasal disease. Patients fulfilling criteria for a diagnosis of AFS have a poor prognosis often requiring multiple surgeries. The detection of 'allergic mucin' with mucus containing clusters of eosinophils and the detection of fungi by histological examination or culture is key criteria necessary for diagnosis. This study was performed to assess the strength of the association of the presence of fungi with the presence of eosinophils in a group of patients with chronic rhinosinusitis and controls. METHODS: Thirty patients with a clinical diagnosis of chronic rhinosinusitis and 10 individuals as control group were selected for the study. Total serum IgE level testing, nasal mucus cytology and fungal culture were performed in all subjects. RESULTS: Fungal spores were present in the nasal mucus in 14 patients with rhinosinusitis, and in 7 controls. The detection of eosinophils on cytology correlated significantly both with a clinical diagnosis of chronic rhinosinusitis (95% confidence intervals (CI) 0.34-0.81) and with the presence of fungal elements on cytology (p=0.02). The average serum IgE level was higher in patients with fungal spores (p=0.039). CONCLUSION: In certain susceptible individuals inhaled fungi may provoke an eosinophilic response. This response varies from simple eosinophilic inflammation to classic allergic fungal sinusitis.     

‘Eosinophilic Fungal Rhinosinusitis’: A Common Disorder in Europe?

OBJECTIVES/HYPOTHESIS: The traditional criteria for the diagnosis of allergic fungal sinusitis include chronic rhinosinusitis, "allergic mucin" (mucus containing clusters of eosinophils), and detection of fungi by means of histological examination or culture. In 1999, a group of Mayo Clinic researchers, with a novel method of mucus collection and fungal culturing technique, were able to find fungi in 96% of patients with chronic rhinosinusitis. Immunoglobulin E-mediated hypersensitivity to fungal allergens was not evident in the majority of their patients. Because the presence of eosinophils in the allergic mucin, not a type I hypersensitivity, is probably the common denominator in the pathophysiology of allergic fungal sinusitis, the Mayo Clinic group proposed a change in terminology from allergic fungal sinusitis to eosinophilic fungal rhinosinusitis. Using new techniques of culturing fungi from nasal secretion, as well as preservation and histological examination of mucus, we investigated the incidence of "eosinophilic fungal rhinosinusitis" in our patient population. STUDY DESIGN METHODS: In an open prospective study nasal mucus from patients with chronic rhinosinusitis as well as from healthy volunteers was cultured for fungi. In patients, who underwent functional endoscopic sinus surgery, nasal mucus was investigated histologically to detect fungi and eosinophils within the mucus. RESULTS: Fungal cultures were positive in 84 of 92 patients with chronic rhinosinusitis (91.3%). In all, 290 positive cultures grew 33 different genera, with 3.2 species per patient, on average. Fungal cultures from a control group of healthy volunteers yielded positive results in 21 of 23 (91.3%). Histologically, fungal elements were found in 28 of 37 patients (75.5%) and eosinophilic mucin in 35 of 37 patients (94.6%). Neither fungi nor eosinophils were present in 2 of 37 patients (5.4%). CONCLUSIONS: Our data show that the postulated criteria of allergic fungal sinusitis are present in the majority of patients with chronic rhinosinusitis. Either those criteria will be found to be invalid and need to be changed or, indeed, "eosinophilic fungal rhinosinusitis" exists in the majority of patients with chronic rhinosinusitis. Based on our results, fungi and eosinophilic mucin appear to be a standard component of nasal mucus in patients with chronic rhinosinusitis.     

Chronic invasive fungal rhinosinusitis: two new cases and review of the literature

BACKGROUND: Chronic invasive fungal rhinosinusitis is rare in the immunocompetent patient. Few cases have been published except for in a specific geographic area (Sudan, India). METHODS AND RESULTS: We reported two new cases of chronic invasive fungal rhinosinusitis due to Aspergillus, which was successfully treated, to analyze the different clinical, radiological, and mycological criteria. CONCLUSION: Through these two new clinical cases and the analysis of the literature, we suggested, in the absence of general agreement on the surgical and medical management, the current strategies available for this rare pathology. New antifungal drugs seem to be an efficient alternative to classic antifungal agents, especially those that require an extended course of oral therapy for the chronic invasive form.     

Tissue-specific immunoglobulin E in maxillary sinus mucosa of allergic fungal sinusitis

OBJECTIVE: The objectives of this prospective study were to analyze the specific immunoglobulin E (sIgE) in maxillary sinus mucosa and to determine the importance of local tissue sIgE in the patients with allergic fungal sinusitis (AFS). METHODS: We investigated tissue-specific IgE in the maxillary sinus mucosa. Thirty-four patients with rhinosinusitis and nasal polyposis were included in the study. The patients were divided into three groups--AFS, fungal sinusitis and chronic rhinosinusitis (CRS). The sIgE profile of the maxillary sinus mucosa was studied by the CAP method. Other parameters, such as allergic symptoms, presence of fungi hyphae and eosinophilic mucin in the sinus cavities as well as computed tomography (CT) scanning findings were also evaluated in all groups. RESULTS: All patients in the AFS group had allergic symptoms, and the serum IgE test was positive to mites or house dust, but none had a positive serum IgE response to Aspergillus. However, 85.7% of this group had tissue sIgE to Aspergillus. CONCLUSIONS: The local tissue sIgE profile is more specific than the systemic sIgE profile in determining the allergic status of AFS patients. Tissue sIgE for fungi may be considered as a part of AFS diagnostic criteria.     

Incidence and presentation of fungal sinusitis in patient diagnosed with chronic rhinosinusitis

Significant number of patients diagnosed with chronic rhino sinusitis often tend to have a final diagnosis of fungal sinusitis. We wanted to find out (a) The incidence of patients with fungal sinusitis in those patients who were initially diagnosed as chronic rhinosinusitis. (b) The presentation of fungal sinusitis patients who were initially diagnosed as CRS. Retrospective chart review of 242 patients diagnosed as CRS from May 2006 to April 2009. The various symptoms and signs of those diagnosed initially as CRS, who were then diagnosed as fungal sinusitis were tabulated. Radiological and serological investigations were then analyzed. The microbiology of various species that were cultured in those identified as fungal sinusitis were also presented. Out of 242 patients diagnosed with CRS, 67 patients had clinical and radiological evidence of fungal sinusitis but only 24 of these patients had fungal organisms identified. Majority of them were Aspergillus fumigatus. Clinical suspicion of fungal sinusitis should be made in those patients presenting with CRS with the following signs and symptoms of nasal obstruction, discharge and polyps. Most of those fungus were Aspergillus fumigatus and responded well to treatment.     

New paradigm for the roles of fungi and eosinophils in chronic rhinosinusitis

PURPOSE OF REVIEW: Chronic rhinosinusitis represents a challenge with its poorly understood pathophysiology and limited treatment options. Potential roles of fungi and eosinophils in the etiology and pathophysiology of chronic rhinosinusitis are summarized. RECENT FINDINGS: Previously, the fungal role in chronic rhinosinusitis was limited to the rare subgroup, allergic fungal rhinosinusitis. Critical examination of earlier diagnostic criteria for allergic fungal rhinosinusitis reveals limitations. By using updated diagnostic standards and novel sensitive techniques to detect fungi, a higher number of patients can now be diagnosed with fungal rhinosinusitis. A novel non-IgE-mediated immunologic mechanism in chronic rhinosinusitis patients links the predominant eosinophilic inflammation to certain fungi. Overall, these new findings have implications for surgical and medical approaches, including anti-inflammatory and antifungal medications. SUMMARY: Several classification schemes and diagnostic criteria describe chronic rhinosinusitis and make comparisons difficult. Preselection of patient groups within the chronic rhinosinusitis population and the lack of sensitive diagnostic techniques have prevented a full understanding of the syndrome complex of chronic rhinosinusitis. New results suggest a broader role for fungi in the pathophysiology of chronic rhinosinusitis, linking the eosinophilic inflammation to the presence of certain molds in the nasal and paranasal cavities. Although fungi are commonly found in nearly everyone, only chronic rhinosinusitis patients respond to them with an eosinophilic inflammation. These findings support a shift in the etiologic understanding of chronic rhinosinusitis away from a bacteriologic infectious pathogenesis to a fungal-driven inflammatory pathophysiology. Herein, the authors review earlier studies and describe an updated view on an old paradigm.     

Culture-positive allergic fungal sinusitis

Allergic Aspergillus sinusitis is a well-defined clinical and histologic entity, although surprisingly few reported cases have yielded any fungal growth on culture. Taking advantage of recent changes in the identification and classification of certain groups of fungi, we were able to identify a specific fungal organism in 19 of 22 consecutive patients with a histologic diagnosis of allergic fungal sinusitis over the past 2 1/2 years. Aspergillus was found in only one patient, while an organism in the family of dematiaceous fungi was found in 18 patients. Of these patients, the genus Bipolaris was the most commonly represented, while Exserohilum, Curvularia, and Alternaria species were seen with less frequency. Thus, it appears that Aspergillus may not be the most common etiologic agent in allergic "Aspergillus" sinusitis. Allergic fungal sinusitis is not unusual and its incidence may be increasing. On initial clinical evaluation it may be easily mistaken for malignancy or invasive fungal disease with the potential for overly aggressive treatment. Preoperative suspicion of allergic fungal sinusitis based on clinical and roentgenographic findings along with careful communication with the mycology laboratory about the possibility of dematiaceous fungal growth are necessary for proper diagnosis.     

Noninvasive fungal sinusitis (fungus ball)--diagnostic difficulties

Noninvasive fungal sinusitis (fungus ball) is usually found in one sinus and the most frequently is caused by Aspergillus. Diagnostic criteria are based on histopathology, and fungal cultures are frequently negative. The clinical symptomatology mimics chronic rhinosinusitis and radiology, specially CT and MRI are helpful for making decision of surgery. The authors present 4 cases of fungus ball of the paranasal sinus. In one case clinical symptoms, endoscopic examination of nasal cavity and CT scans suggested foreign body in the maxillary sinus. In other case clinical and radiological evidences made us to thing of neoplasmatic disease of the frontal sinus. In remaining two cases mycetoma was found in the sphenoid sinus. Surgical removal was the treatment in all cases and followed by systemic antifungal therapy in one case because of bone destruction. Histopathology revealed hyphae of Aspergillus without evidence of tissue invasion, fungal cultures in two cases were negative, an in other two Aspergillus fumigatus culture were obtained.     

Proteomics blood testing to distinguish chronic rhinosinusitis subtypes

Objectives: To evaluate the potential of surface enhanced laser desorption/ionization time‐of‐flight mass spectrometry (SELDI‐TOF‐MS) proteomic profiling of serum samples to distinguish chronic rhinosinusitis subtypes. Study Design: Translational study of serum samples from prospectively enrolled patients undergoing sinus surgery. Methods: Patients undergoing endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis were prospectively enrolled in an ongoing, institutional review board approved proteomics study. SELDI‐TOF‐MS was performed on 42 serum samples in patients with chronic rhinosinusitis with nasal polyposis (15 patients diagnosed with allergic fungal rhinosinusitis, 10 patients with Samter's triad, and 17 with chronic rhinosinusitis with nasal polyposis). Classification tree analysis on protein spectra developed from peaks detected in the 0 to 100 kD range was performed to identify disease subtypes. Results: SELDI‐TOF‐MS correctly identified patients with allergic fungal rhinosinusitis from serum samples with 84% sensitivity and 90% specificity, and correctly identified patients with Samter's triad with 88% sensitivity and 88% specificity in two subtype comparison groups. SELDI‐TOF‐MS correctly identified patients with allergic fungal rhinosinusitis with 76% sensitivity and 82% specificity, and correctly identified patients with Samter's triad with 80% sensitivity and 90% specificity in three subtype comparison groups. Conclusion: The study provides molecular evidence that allergic fungal rhinosinusitis is a discrete subtype of chronic rhinosinusitis. SELDI‐TOF‐MS is a promising technology that could lead to the development of a rapid blood test, to identify severe chronic rhinosinusitis subtypes. Further investigation into the utility of this technology is warranted.     

Allergic<Emphasis Type="Italic"> Aspergillus flavus</Emphasis> rhinosinusitis: a case report from Qatar

Fungal involvement in rhinosinusitis is classified into four major forms: allergic, mycetoma, chronic invasive (indolent) and acute invasive (fulminant). It can become life threatening if not diagnosed and treated properly. The preliminary diagnosis is usually made by nasal endoscopy and computed tomography (CT) imaging, but tissue biopsy and culture are of vital importance in confirming the disease and in planning treatment. We present a case of allergic fungal rhinosinusitis (AFS) caused by Aspergillus flavus. The clinical manifestation of the disease was the presence of an extensive left nasal polyp. An allergic workup revealed systemic eosinophilia (11.7%), high serum IgE levels (1,201 IU/ml) and a positive skin test for Aspergillus. CT scan showed a total opacification and expansion of the left nasal cavity and sinuses, with a secondary inflammatory reaction on the right side. There was no bony erosion beyond the sinus walls. The patient was operated on using an endoscopic approach (polypectomy and ethmoidectomy), where an abundant amount of allergic fungal mucin and dark crusts were found filling the sinuses. Fungal hyphae were evident in histopathological sections of the removed mucin. Culture of the debris resulted in the growth of Aspergillus flavus. The patient received a full course of systemic and topical steroids. The serum IgE level had dropped to 353 IU/ml and the peripheral eosinophil count to normal (1.38%) by the 10th postoperative month. Surgical debridement and corticosteroids may keep the disease quiescent for a long time.     

Eosinophilic Mucus Chronic Rhinosinusitis: Clinical Subgroups or a Homogeneous Pathogenic Entity?

BACKGROUND: Eosinophilic mucus chronic rhinosinusitis (EMCRS) can be subclassified using the criteria of detection of fungi in eosinophilic mucus and systemic fungal allergy. Allergic fungal sinusitis (AFS), a subgroup of EMCRS characterized by the presence of fungal allergy, is proposed to be an immunoglobulin (Ig)E-driven disease, distinct from other EMCRS subgroups. However, our recent studies cast doubt on the central pathogenic role of allergy in AFS. The purpose of this study was to examine the clinical features of EMCRS patients from the different subcategories to determine the relevance of this classification system. METHOD: The demographic, clinical, and immunologic characteristics of the EMCRS subgroups were examined prospectively and compared with three control groups: healthy volunteers, allergic rhinitis with fungal allergy, and chronic rhinosinusitis without eosinophilic mucus. RESULTS: EMCRS patients with allergy were younger than those without. There was no significant difference in clinicopathologic parameters between EMCRS subgroups. As a single group, EMCRS had a more severe sinus disease compared with chronic rhinosinusitis patients. CONCLUSIONS: AFS was not clinically distinct from other subgroups of EMCRS. However, eosinophilic mucus may mark a more severe and distinct form of sinus disease.     

Categorization of eosinophilic chronic rhinosinusitis

PURPOSE OF REVIEW: The presence of eosinophilia histopathologically in sinusitis is frequently associated with greater disease objectively and a decreased likelihood of surgical success. Eosinophilic chronic rhinosinusitis encompasses a wide variety of etiologies and associations that can be grouped under this umbrella term. In addition, this term can be further divided into those patients with no polyps and those with polyps. The purpose of this review is to detail the epidemiology of eosinophilic chronic rhinosinusitis, to define known and potential subcategories, and to discuss targeted therapeutic interventions. Eosinophilia is frequently, but not exclusively, caused by IgE-mediated hypersensitivity and is dominated by the associated cytokine milieu of Th2 inflammation. Thus, allergic rhinitis or allergy is a subcategory and not synonymous with eosinophilic chronic rhinosinusitis. RECENT FINDINGS: Recent findings supporting mechanisms that promote eosinophilic infiltration are discussed and include the following subcategories: super antigen-induced eosinophilic chronic rhinosinusitis, allergic fungal sinusitis, nonallergic fungal eosinophilic chronic rhinosinusitis, and aspirin-exacerbated eosinophilic chronic rhinosinusitis. Undoubtedly there are other mechanisms and categorizations of eosinophilic chronic rhinosinusitis as yet unknown. It is possible, and in fact probable, that some patients may have overlapping mechanisms for eosinophilia. Corticosteroid therapy is an important treatment across all eosinophilic disorders and a profoundly potent but nonspecific antiinflammatory agent. Within each subcategory a specific antibacterial, antifungal, or immune modulation may be indicated. SUMMARY: The subcategories of eosinophilic chronic rhinosinusitis are discussed in light of recent findings and treatment recommendations.     

Overview of fungal rhinosinusitis

The incidence of fungal rhinosinusitis has increased to such extent in recent years that fungal infection should be considered in all patients with chronic rhino sinusitis. In India though the disease was reported earlier only from northern regions of this country, nowadays the disease is increasingly diagnosed from other parts as well. The disease has been categorized with possible five types: acute necrothing (fulminant), chronic invasive, chronic granulomatous invasive, fungal hall (sinus mycetoma), allergic. The first three types are tissue-invasive and the last two are non-invasive fungal rhinosinusitis. However, the categorization is still controversial and open to discussion. Chronic fungal rhinosinusitis can occur in otherwise healthy host and Aspergillus flavus is the common etiological agent in Indian scenario. The pathophys iologic mechanism of the disease remains unclear. It may represent an allergic IgE response, a cell-mediated reaction, or a combination of two. Early diagnosis may prevent multiple surgical procedures and lead to effective treatment. Histopathology and radio-imaging techniques help to distinguish different types and delineate extension of disease process. Culture helps to identify the responsible etiological agent. The presence or absence oj precipitating antibody correlates well with disease progression or recovery. The most immediate need regarding management is to establish the respective roles of surgery and antifungal therapy. Non-invasive disease requires surgical debridement and sinus ventilation only, though, additional oral or local corticosterold therapy may be beneficial in allergie type. For invasive disease, the adjuvant medical therapy is recommended to prevent recurrence and further extension. Itraconazole has been found as an effective drug in such situation. Patients with acute neerotizing type require radical surgery and amphotericin B therapy.     

Allergic fungal sinusitis.

In summary, AFS is a newly recognized form of sinusitis, appearing in otherwise healthy young adults with a history of chronic bacterial or polypoid rhinosinusitis refractory to conventional therapy. Radiologic study may show patchy opacification or calcifications of the sinuses on CT. The patients have an elevated total IgE, peripheral eosinophilia, and positive skin tests for fungal antigens. They may also have elevated serum fungal allergen-specific IgE and IgG and precipitating antibodies to Aspergillus, Curvularia, or other fungi. Diagnostic and therapeutic surgical drainage of the sinuses will establish a definitive diagnosis by identifying the typical allergic mucin with eosinophils, Charcot-Leyden crystals, few fungal hyphae on silver stain, and a lack of tissue invasion. Treatment, other than surgical drainage, consists of systemic corticosteroids to prevent recurrence of disease.     

Isolation of fungi by standard laboratory methods in patients with chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS: Allergic fungal sinusitis and the role of fungi in the pathogenesis of chronic rhinosinusitis are topics of interest and controversy in rhinology. The classification of chronic rhinosinusitis as either a bacterial infection or an allergic (eosinophilic) reaction to fungi has significant implications for treatment of this disease process. We designed a study to determine whether standard isolation techniques, as employed in a university hospital mycology laboratory, could isolate and identify fungi in the intraoperative specimens from patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. STUDY DESIGN: Forty-five random patients with a diagnosis of chronic rhinosinusitis by clinical and computed tomography criteria underwent endoscopic sinus surgery during 2001, performed by two senior surgeons (J.B.J., R.A.L.). Specimens of mucin, sinus secretions, and/or tissue were obtained intraoperatively and sent to the New York University Medical Center (New York, NY) mycology laboratory for isolation and identification of fungi. METHODS: Specimens were treated with Sputolysin and chloramphenicol; plated on Sabouraud, ChromAgar/Candida, Mycosel, and Niger seed agar plates; and incubated at 30 degrees C (or 37 degrees C) for up to 1 month. RESULTS: We were able to demonstrate the presence of fungi in 56% of intraoperative specimens obtained from patients undergoing surgery for chronic rhinosinusitis. CONCLUSIONS: Using a standard hospital mycology laboratory protocol, which is relatively inexpensive and readily available, fungus can be isolated from a majority of patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. Educational statement: Discuss the possible role of fungus in chronic rhinosinusitis and evaluate the efficacy of documenting the presence of fungus in a routine fashion to encourage clinically relevant directed treatments.)     

Investigations on allergic fungal genesis of chronic rhinosinusitis

BACKGROUND: The incidence of allergic fungal sinusitis (AFS) is estimated differently. The importance of hyphal findings in nasal mucus for initiation of chronic hyperplastic sinusitis is not proven. METHODS: 124 patients with clinical signs and CT-scan findings of a chronic-hyperplastic rhinosinusitis were treated by functional endoscopic sinus surgery. During the operation a thick mucus was found in each patient. The mucus was isolated and investigated by histopathological analysis with special Grocott-stain and a culture for fungal growth was initiated. Furthermore the diagnostic for allergic reactions against fungus was done by prick- and RAST-tests. RESULTS: 21 patients had positive histopathological findings of fungus. In 10 cases fungal hyphae were found embedded in typical eosinophilic mucus. A positive allergic reaction against fungus was seen in 7 of these 10 patients. The culture results showed different pictures according to the isolated species, in 3 cases of the 10 AFS cases the culture was negative. The other 11 cases of 21 positive histological findings of fungus were cases of a fungus ball. The other 103 patients were without any sign for fungus in the HE- or Grocott-stain. CONCLUSIONS: A high incidence of AFS is not evident in group of chronic hyperplastic rhinosinusitis. The presence of eosinophilic "allergic" mucus is not the evidence for AFS. The inflammatory cascade leading to the clinical picture is a multifactorial event. The role of detectable fungus hyphae have to be estimated by further investigations.     

Preoperative diagnosis of allergic fungal sinusitis

OBJECTIVES/HYPOTHESIS: Although the diagnosis of allergic fungal sinusitis is mainly based on characteristic histopathological findings, certain preoperative diagnostic criteria have been proposed. However, their usefulness in differentiating allergic fungal sinusitis from other sinus diseases is unknown. The objective of the study was to identify accurate preoperative diagnostic parameters for allergic fungal sinusitis. STUDY DESIGN: Prospective, comparative study. METHODS: Twenty consecutive cases of allergic fungal sinusitis were evaluated prospectively and compared with 16 cases of ethmoidal polyposis and 5 cases of invasive sinus aspergillosis, with regard to various clinical, radiological, and immunological parameters. All patients were categorized based on histopathological findings. RESULTS: Nasal polyps were seen in all 20 cases of allergic fungal sinusitis, all 16 cases of ethmoidal polyposis, and 2 of 5 cases of invasive sinus aspergillosis. Computed tomography (CT) scan hyper-attenuation was seen in all 20 cases of allergic fungal sinusitis but also in 2 (13%) cases of ethmoidal polyposis and 2 (40%) cases of invasive sinus aspergillosis. Serum levels of specific anti-Aspergillus immunoglobulin E were elevated in 14 (70%) cases of allergic fungal sinusitis, 2 (13%) cases of ethmoidal polyposis, and 3 (60%) cases of invasive sinus aspergillosis. The combination of all three (ie, nasal polyps, CT scan hyper-attenuation, and elevated titers of anti-Aspergillus immunoglobulin) was not found in any case of ethmoidal polyposis or invasive sinus aspergillosis. This triad demonstrated a sensitivity of 70% and a specificity of 100% for the preoperative diagnosis of allergic fungal sinusitis. CONCLUSIONS: Nasal polyps, CT scan, and specific immunoglobulin E titers, when considered in combination, have a high preoperative diagnostic value in allergic fungal sinusitis. However, they should not be considered in isolation because considerable overlap occurs with invasive sinus aspergillosis and ethmoidal polyposis.     

Increasing diagnostic yield in allergic fungal sinusitis

Diagnosis of allergic fungal sinusitis (AFS) in patients who present with rhinosinusitis and polyposis is based upon certain clinical, histopathological and mycological histopathological criteria are the demonstration of fungal hyphae in allergic mucin and absence of tissue invasion in the excised polyps. Previous reports have indicated difficulty in demonstrating fungal hyphae on histological examination in up to 75 per cent of cases. Analysis of a series of 25 patients with AFS, suggested methods to ensure demonstration of fungal hyphae and thus increase diagnostic yield in cases with suspected AFS. criteria. Specific diagnostic     

Fungal infections of the head and neck: an update

Despite the vast literature regarding fungal infections of the head and neck, little has changed in diagnosis or management of these infections except in the nose and sinuses. Three main points regarding fungal involvement in the paranasal sinuses are evident now. First, fungi may be important in a significant percentage of patients with chronic rhinosinusitis. Second, the pathophysiologic mechanism responsible for fungal rhinosinusitis remains unclear. It may represent an allergic IgE response, a cell-mediated reaction, or a combination of the two. Finally, there is certainly a spectrum of disease thus far defined: allergic fungal sinusitis as defined by Bent and Kuhn [35], eosinophilic mucin rhinosinusitis defined by Ferguson [50], and eosinophilic fungal rhinosinusitis as proposed by Ponikau [45]. Fungal infections of the head and neck are panoramic in distribution and pathophysiology. They represent a broad range of disease of which medical science has only recently begun to uncover the surface. As research begins to unravel the complex host defense mechanisms against these pathogens from a cellular and even genetic level, the body of knowledge will continue to increase exponentially and the ability to treat patients suffering from fungal infections will improve.