Invasive fungal sinusitis and complications of rhinosinusitis

Acute fulminant invasive fungal sinusitis in an immunocompromised host and bacterial rhinosinusitis with intracranial or orbital extension are challenging to manage and constitute true otolaryngic emergencies. In the absence of rapid diagnosis and treatment, these diseases can be fatal. In this article, the complications of bacterial rhinosinusitis are divided into three categories: local, orbital, and intracranial. They vary in their characteristics and severity according to their location, duration, and specific symptoms. This article reviews the pathophysiology, clinical presentation, diagnosis, and treatment options of acute invasive fungal sinusitis rhinosinusitis, the most common subtype in the United States.     

Unusual fungal pathogens in fungal rhinosinusitis

Approximately 300 fungal species are known to cause mycotic disease in humans and other animals. More than 50 of these species are documented as agents of rhinosinusitis. Most such infections are caused by species of Aspergillus, Rhizopus, Alternaria, Bipolaris, and Curvularia. A growing number, however, has been attributed to lesser known fungi. Here, 38 fungi that are unusual causes of rhinosinusitis are tabulated and referenced in conjunction with their associated symptoms.     

An algorithmic approach to the diagnosis and management of invasive fungal rhinosinusitis in the immunocompromised patient

Acute invasive fungal rhinosinusitis is a difficult disorder to diagnose and treat. A systematic approach to the susceptible patient, however, leads to an earlier diagnosis with improved survival. Early evaluation with rigid nasal endoscopy with frozen section biopsy of suspicious lesions or the middle turbinate should be considered in the high-risk population. Complete surgical resection and the reversal of neutropenia appear to be critical elements in achieving a successful outcome in patients with invasive fungal rhinosinusitis.     

Allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis is a phenotype of chronic rhinosinusitis with nasal polyposis, characterized by type 1 hypersensitivity to fungi, eosinophilic mucin with fungal hyphae in sinus secretions, and propensity for mucocele formation and bone erosion. Although its differentiation from other forms of chronic polypoid rhinosinusitis with eosinophilic mucin is sometimes problematic, type 1 hypersensitivity is a component of the disease process. Medical and surgical management can be augmented by immunotherapy directed toward the patient's specific allergen sensitivities. The primary rationale for immunotherapy is to control the allergic diathesis that may be contributing to the patient's chronic sinus inflammation.     

变应性真菌性鼻-鼻窦炎研究进展

变应性真菌性鼻 -鼻窦炎是一个近 2 0多年才被认识的一个特征性疾病实体 ,为慢性鼻 -鼻窦炎鼻息肉病的一个特殊类型。其临床表现并无特异性 ,但有典型的 CT和 MRI影像学所见 ,术中和病理学证实变应性粘蛋白的存在是本病诊断的重要指标。在整个治疗中手术治疗是最主要的 ,已从根治性手术转变为更“保守但彻底”的手术。手术 +类固醇药物 +免疫治疗的综合治疗是提供本病长期得到控制的最佳方案。在研究本病的发展、诊断和治疗中常遇到不少难题 ,有待进一步研究     

鼻腔鼻窦侵袭型真菌病(附2例报告及文献复习)

目的探讨鼻腔鼻窦侵袭型真菌病的发病机理、临床表现及分类、诊断和治疗。方法报告2例鼻腔鼻窦侵袭型真菌病的临床资料，复习相关文献。结果①鼻腔鼻窦侵袭型真菌病发病率低，但破坏性强，易迅速向周围邻近组织扩散，造成功能障碍。②临床分类：根据其临床表现和过程分为慢性、急性爆发性及肉芽肿性侵袭型鼻腔鼻窦真菌病。③诊断：主要依据临床表现、影像学、病理学及微生物学检查，真菌培养阳性可以确诊。④治疗：尽早、合理的手术治疗是关键，辅以抗真菌、纠正全身疾病、提高机体免疫等综合治疗。⑤2例病人鼻内镜下鼻窦根治，感染控制，病灶吸收，功能恢复。结论侵袭型鼻腔鼻窦真菌病是一种少见的真菌性疾病，病情凶险，预后差。早期诊断、以手术为主的综合治疗能有效提高病人的生存率、降低致残率。     

Invasive fungal rhinosinusitis associated with COVID-19: Course changes and prognosis predictors

BackgroundThis study aimed to analyze the behavior of acute invasive fungal rhinosinusitis (AIFRS) associated with COVID-19 infection as there has been an increase in the rate of AIFRS cases in the last two years, and many reports connected this rising with the COVID-19 infection. We studied most factors that may impact the prognosis as a trial to find the most affecting factors to improve the outcomes.MethodsIt was a retrospective observational study that included cases from four tertiary referral institutions between November 2020 to February 2022. We included sixty-six patients who suffered from AIFRS associated with confirmed COVID-19. We observed the prognosis of all included patients with a six-month follow-up. We correlated the prognosis with many factors, such as demographic data, medical conditions, blood investigations, the features of fungal infections, and management.ResultsForty-two patients (64%) survived after the AIFRS associated with COVID-19, and twenty-two patients (36%) died. High doses of corticosteroids with prolonged use were the main factors that affected the behavior of the AIFRS associated with COVID-19. HbA1c was a good predictor of the prognosis; a level less than 9.35% may indicate survival with 87.5% sensitivity.ConclusionsAccording to this multi-center study, the mortality of the AIFRS associated with COVID-19 was high. The behavior was affected by glycemic control, the type of fungal species, and the type of antifungal therapy. Early surgical debridement, a combination of Amphotericin B with Voriconazole, and anticoagulants helped improve the prognosis.     

Aggressive combination treatment for invasive fungal sinusitis in immunocompromised patients

Invasive sinonasal fungal disease is a potentially fatal complication of chemotherapy-induced immunosuppression and neutropenia. We reviewed the outcomes of seven cancer patients who had been diagnosed with invasive fungal sinusitis; six patients had hematologic malignancies and one had breast cancer. At the time of their sinus diagnosis, all patients had been hospitalized and were receiving combination chemotherapy for their underlying malignancy. Impairment of their immune function was characterized by an absolute neutrophil count of less than 1,000/mm3. Aggressive management of their sinonasal fungal disease consisted of surgical debridement and systemic amphotericin B for all patients, and treatment with granulocyte colony-stimulating factor for two patients. Invasive Aspergillus infection was identified in six patients and invasive Candida albicans infection in one. Although the prognosis for these patients was poor and two patients died of the fungal infection, the aggressive treatment strategy resulted in long-term survival for the remaining five patients.     

Histopathology of fungal rhinosinusitis

Treatments for the various kinds of fungal rhinosinusitis are fundamentally different, and it is essential to obtain an accurate diagnosis of the particular syndrome in a given case. Microscopic examination of specimens is the most definite and rapid means of establishing a diagnosis of fungal rhinosinusitis. This article compares the utility of various staining and microscopy methods, presents two keys for the algorithmic evaluation of fungal cells as seen in clinical specimens, discusses practical aspects of fungal spore formation within clinical specimens, and reevaluates the role of Candida albicans in rhinosinus disease.     

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.     

Definitions of fungal rhinosinusitis

Classification of fungal rhinosinusitis is important for the accurate prediction of prognosis and direct therapy. The most important distinction is between invasive and noninvasive fungal rhinosinusitis. Within the invasive division are acute invasive and chronic invasive (granulomatous and nongranulomatous forms) rhinosinusitis. Within the noninvasive division are saprophytic colonization, fungus balls, and allergic fungal rhinosinusitis. This article briefly outlines the definition and management of each of these manifestations.     

Chronic invasive fungal rhinosinusitis

Chronic invasive fungal rhinosinusitis is an increasingly recognized, but inadequately characterized, disease entity which is separate and distinct from acute fulminant invasive fungal sinusitis and allergic fungal sinusitis. Chronic invasive fungal rhinosinusitis is divided into granulomatous and nongranulomatous subtypes based on histopathology, but the clinical distinction between the two subtypes is not clear. Current management includes varying degrees of surgical débridement and a prolonged course of antifungal agents. A protracted clinical course with recurrence after treatment is common.     

Geographic variation in allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) has a worldwide distribution. This survey of 20 otolaryngologic practices throughout the United States confirmed a variation in the frequency of AFRS relative to endoscopic sinus procedures performed for all other diagnoses. The highest incidence occurred in Memphis, Tennessee at 23%, with three other southern practices reporting a frequency of at least 10%. In the northern locations the frequency ranged from 0 to 4%. No correlation with mould counts was demonstrated, possibly because of incomplete mould data relative to most of the surgical locations.     

真菌性鼻-鼻窦炎研究进展

近年来真菌性鼻-鼻窦炎在临床上日益多见,其病原菌、临床表现、诊断以及治疗均与传统的鼻-鼻窦炎有所不同。不同类型的真菌性鼻-鼻窦炎由于致病的病原菌不同,在临床表现、诊断、治疗以及预后方面有各自的特点,如非侵袭性真菌性鼻-鼻窦炎的治疗以手术为主,而侵袭性真菌性鼻-鼻窦炎除手术外,还需在治疗全身原发疾病基础上全身使用抗真菌药物。本文就各类真菌性鼻-鼻窦炎的病因、临床表现、诊断、治疗及预后等方面做一综述。     

Acute invasive fungal rhinosinusitis: our experience with 19 patients

Acute invasive fungal rhinosinusitis (AIFR) is a potentially fatal infection that affects immunocompromised patients. Early diagnosis and treatment, including aggressive surgical debridement, antifungal medication, and correction of underlying predisposing factors are essential for recovery. The aim of this study was to review our experience with AIFR. The records of 19 patients histopathologically diagnosed with invasive fungal rhinosinusitis were retrospectively reviewed. Demographic data, presenting symptoms and signs, underlying diseases, and outcomes of the patients are presented and invasive fungal rhinosinusitis is discussed in light of the current literature.