Total IgE levels do not change 1 year after endoscopic sinus surgery in patients with chronic rhinosinusitis

BACKGROUND: Total IgE levels positively correlate with the amount of mucosal thickening on sinus CT scans. Our objective was to investigate whether the levels of total serum IgE decreased 1 year after endoscopic sinus surgery in patients with chronic rhinosinusitis, suggesting that the total IgE was influenced by the sinus disease. METHODS: 55 patients about to undergo endoscopic sinus surgery for chronic rhinosinusitis were enrolled in a prospective clinical study. All patients had preoperative sinus computerized tomography (CT) scans and levels of total serum IgE measured before surgery and 1 year postoperatively. RESULTS: Preoperative total IgE levels showed a significant correlation with the extent of disease on sinus CT (r(s) = 0.413, p = 0.002). Total serum IgE levels did not show any statistically significant change from the preoperative values when measured 1 year postoperatively (324.25 +/- 217.30 ng/ml vs. 326.35 +/- 204.50 ng/ml; p = 0.61). CONCLUSIONS: The levels of total serum IgE do not change after sinus surgery for chronic rhinosinusitis. IgE levels in chronic rhinosinusitis may reflect a systemic factor in disease pathogenesis, and are probably not related to the amount of local inflammation within the sinuses.     

Primary sinonasal tuberculosis confined to the unilateral maxillary sinus

Extrapulmonary tuberculosis is not rare and occurs mainly in the head and neck region. Cervical tuberculous lymphadenopathy is the most common form of extrapulmonary tuberculosis. Sinonasal tuberculosis is known to occur very rarely due to the protective functions of sinonasal mucosa. Although some signs of sinonasal tuberculosis may be present, such as associated facial abscesses, the symptoms and signs are usually nonspecific. Clinical suspicion is important for timely diagnosis and proper management of sinonasal tuberculosis due to its rarity and nonspecific clinical presentation. We report a case of tuberculosis confined to the unilateral maxillary sinus that was first misdiagnosed as recurrent rhinosinusitis after endoscopic sinus surgery.     

Fluticasone propionate aqueous nasal spray does not influence the recurrence rate of chronic rhinosinusitis and nasal polyps 1 year after functional endoscopic sinus surgery

BACKGROUND: Local corticosteroids are widely used in the treatment of nasal polyps and chronic rhinosinusitis both before and after nasal surgery. Their efficacy after functional endoscopic sinus surgery (FESS) has not been fully established by placebo-controlled trials. OBJECTIVE: This double-blind placebo-controlled randomized study was performed in order to investigate whether fluticasone propionate aqueous nasal spray (FPANS) reduces the recurrence rate of nasal polyps and chronic rhinosinusitis during the first year after FESS. PATIENTS AND METHODS: The trial looked at 162 patients aged 18 years and older requiring FESS for chronic rhinosinusitis or nasal polyps. After FESS combined with peri-operative systemic corticosteroids, patients were randomized and given FPANS 400 microg b.i.d., FPANS 800 microg b.i.d. or placebo b.i.d. for the duration of 1 year. Patients were withdrawn from the trial (but still included in the study for statistical purposes) if there were recurrent or persistent diseases, defined as progressive regrowth of nasal polyps, recurrent signs and symptoms of chronic sinusitis combined with abnormalities on computed tomography scan and persistent complaints for at least 2 months after FESS. RESULTS: A significant reduction of symptoms was seen after FESS. After 1 year, 46 patients had been withdrawn from the trial because of recurrent diseases and 32 patients because of persistent symptoms. No differences in the number of patients withdrawn because of recurrent or persistent diseases were found between the patients treated with FPANS and patients treated with placebo. We were also unable to find a positive effect of FPANS compared with placebo in several subgroups such as patients with nasal polyps, high score at FESS or no previous sinus surgery. CONCLUSION: This placebo-controlled study does not show that treatment with FPANS up to 1 year after FESS had a positive effect compared with placebo.     

Isolation of Aspergillus nidulans from a case of fungal rhinosinusitis: a case report

A rare species i.e. A. nidulans is reported as a causative agent of allergic fungal rhinosinusitis in this study. It is an increasingly recognized type of chronic recurring hypertrophic sinus disease. There are more than 185 species of aspergillus and over 95% of all infections are caused by A. fumigatus, A. flavus and A. niger. A. fumigatus alone accounts for the large majority of cases of both invasive and non invasive aspergillosis. A young immunocompetent lady presented with bilateral nasal obstruction due to multiple polypoid mass at Sheth Vadilal Sarabhai General Hospital, Ahmedabad. Provisional diagnosis of sinonasal polyposis possibly due to fungal cause with infiltration in to nasal cavity was made. Bilateral functional endoscopic sinus surgery with polypectomy was done. The specimen was examined by standard methods and the fungus was identified as A. nidulans by slide culture.     

慢性鼻-鼻窦炎患者嗅觉功能与鼻内镜评分、鼻窦CT评分的相关性

目的:研究慢性鼻-鼻窦炎(chronic rhinosinusitis,CRS)患者嗅觉功能与Lund-Kennedy鼻内镜评分、Lund-Mackay鼻窦CT评分的相关性研究分析.方法:选择CRS住院患者200例.其中CRS(不伴鼻息肉)患者:95例;CRS(伴有鼻息肉)患者:105例,每组患者均进行病史采集,嗅觉功能检测、鼻内镜评分以及鼻窦CT评分.应用SPSS 13.0统计软件,对以上两个评分结果与嗅觉功能进行相关性分析.结果:CRS(不伴鼻息肉)或(伴有鼻息肉)患者中,Lund-Mackay鼻窦CT评分结果和Lund-Kennedy鼻内镜评分结果均是:随着嗅觉功能的下降,分数逐渐增加(P<0.01).结论:CRS患者与Kennedy鼻内镜评分和Lund-Mackay鼻窦CT评分均具有相关性;与CRS(不伴鼻息肉)患者的嗅觉功能最密切相关的是Lund-Mackay鼻窦CT评分;与CRS(伴有鼻息肉)患者的嗅觉功能最密切相关的是与Lund-Kennedy鼻内镜评分.     

Risk Model Establishment of Endoscopic Sinus Surgery for Patients with Chronic Rhinosinusitis: a Multicenter Study in Korea

BackgroundEndoscopic sinus surgery (ESS) is the mainstay treatment for refractory chronic rhinosinusitis (CRS). Since various factors may contribute to the surgical outcome, it is challenging for physicians to predict surgical outcomes. The aim of study was to analyze the prognostic factors of postoperative outcomes and to establish the prediction model with the risk factors that impact the postoperative outcomes.MethodsMedical records of CRS patients who underwent ESS at 9 institutions in 2005, 2010, and 2016 were retrospectively reviewed. We classified the patients into 2 groups based on postoperative objective endoscopic outcomes. Demographics, nose-specific symptoms, olfactory function, eosinophil counts in blood (EoB) and nasal tissue (EoT), and Lund-Mackay CT score (LMS) were collected. Univariate and multivariate analyses were performed and established a prediction equation for postoperative endoscopic objective outcomes.ResultsIn total (n = 1,249), 27.0% were not satisfied under postoperative endoscopic examination. Of 10 variables, LMS (> 5), sinus dominancy (maxillary sinus and ethmoid sinus), EoB (> 210), and EoT (> 100) were statistically significant in univariate analysis (P < 0.05, all). In multivariate analysis, EoT (> 100) and LMS (> 5) were significantly associated with poor postoperative outcome. Furthermore, 5 significant variables were employed to establish the risk model of postoperative outcomes and P (the value of prediction probability) = 1 / (1 + exp [−0.392 + 1.088 × EoT (> 100) + 0.123 × mean LMS (> 5) − 0.366 × sinus dominancy (maxillary) + 0.064 × sinus dominancy (similar) + 0.200 × EoB (4%) + 0.344 × EoB (> 210)] was developed.ConclusionTissue eosinophil count and radiographic severity predispose to a poorer outcome of ESS and the risk model established may be helpful to predict postoperative outcomes of ESS.     

Features of airway remodeling and eosinophilic inflammation in chronic rhinosinusitis: is the histopathology similar to asthma?

BACKGROUND: Asthma and chronic rhinosinusitis (CRS) coexist clinically in >50% of patients with CRS. Although epithelial damage and basement membrane thickening are well-known features of airway remodeling in asthma, they have not been described in CRS. OBJECTIVE: In this study, we tested the hypothesis that histopathologic features of asthma, namely, the chronic eosinophilic inflammation, epithelial damage, and basement membrane thickening of the airway mucosa, are also present in sinonasal specimens from patients with CRS. METHODS: We examined histologic specimens from 22 randomly selected patients with refractory CRS undergoing endoscopic sinus surgery and 4 healthy control subjects. The shedding of the epithelium and basement membrane thickening were evaluated by 3 independent observers' scores of hematoxylin-and-eosin staining. Eosinophilic inflammation was monitored with immunohistochemistry for eosinophil major basic protein. A novel, computerized method objectively analyzed confocal microscopic images of major basic protein immunofluorescence to determine areas with the least and most inflammation per specimen. RESULTS: Specimens from all patients with CRS (22/22) revealed epithelial damage (shedding) and basement membrane thickening. Strikingly heterogeneous eosinophilic inflammation, which did not differ between allergic and nonallergic patients, was detected in all patients with CRS and was absent in all healthy control subjects. CONCLUSION: The histopathologic findings of asthma, namely, heterogeneous eosinophilic inflammation and features of airway remodeling, are also present in CRS. These findings, coupled with the common clinical coexistence of both diseases, suggest that the same pathologic disease process is manifest as CRS in the sinonasal tissue and as asthma in the lower airway.     

Cluster analysis of patients with chronic rhinosinusitis and asthma after endoscopic sinus surgery

BackgroundPatients with chronic rhinosinusitis with nasal polyps and asthma (CRSwAS) are highly heterogenous in severity and prognosis. The clinical phenotypes and inflammatory endotypes of CRSwAS and their association with outcomes of endoscopic sinus surgery (ESS) have not been fully studied yet.ObjectiveWe aimed to find out the clinical phenotypes of CRSwAS and explore their relationship with ESS outcomes using cluster analysis.MethodsWe recruited 103 consecutive adult patients with CRSwAS who had undergone ESS and been followed up for more than 1 year. For cluster analysis, we collected the data from 63 variables pertaining to demographic characteristics, preoperative disease status, surgical techniques, postoperative medical treatment, and outcomes. Eosinophilic CRS was defined as greater than or equal to 10 eosinophils/high-power field, and sinus computed tomography was evaluated by Lund-Mackay sinus computed tomography score (LM score).ResultsWe screened 92 eligible patients and 13 preoperative variables for balanced iterative reducing and clustering using hierarchies cluster analysis. Patients with CRSwAS were divided into 4 clusters with distinct ESS outcomes: (1) cluster 1, characterized by aspirin-exacerbated respiratory disease, eosinophilic CRS, high preoperative LM score, moderate-to-severe asthma, and uncontrolled CRS after ESS; (2) cluster 2, characterized as having female dominance (66.67%), non–aspirin-exacerbated respiratory disease, eosinophilic CRS, high preoperative LM score, moderate-to-severe asthma, and uncontrolled CRS after ESS; (3) cluster 3, characterized as having female dominance (95.83%), noneosinophilic CRS, low preoperative LM score, moderate asthma, and controlled CRS after ESS; and (4) cluster 4, characterized as men-only, smoker, noneosinophilic CRS, low preoperative LM score, mild asthma, and controlled CRS after ESS.ConclusionCRSwAS has distinct clusters, each corresponding to unique clinical and inflammatory characteristics and ESS outcomes.     

Surgery for severe rhinosinusitis

Sinusitis is one of the most common reasons patients visit their primary care physician. The etiology of sinusitis is multifactorial in most cases. However, the final common pathway of disruption is usually made with a thorough history. The physical examination is often unremarkable. Complaints of nasal obstruction, mucopuluent nasal drainage, and facial pain/pressure are most diagnostic chronic sinusitis. Isolated headache is an uncommon presenting symptom. Computed tomography scans are the gold standard for diagnostic imaging. They can be used both for diagnosis and surgical treatment. All chronic sinusitis patients, being considered for endoscopic sinus surgery, should have failed a trial of maximal medical therapy. This includes a 4–6 wk course of oral antibiotics, nasal steroids, topical nasal decongestants, and oral prednisone if possible. Patients who fail maximal medical therapy have persistent symptoms that significantly effect their daily activities, have chronic abnormalities on computet tomography scan, and are candidates for endoscopic sinus surgery. Appropriate patient selection and preoperative counseling are key factors in patient satisfaction. Most patients with symptoms that significantly impact their daily activities will receive marked improvement in symptoms after sinus surgery. Endoscopic sinus surgery has undergone radical changes in the last 15 yr. Minimally invasive techniques, combined with advances in instrumentation and computers have reduced postoperative discomfort and improved patient satisfaction.     

Macrophage mannose receptor in chronic sinus disease

BACKGROUND: The role of infectious agents in the onset and maintenance of chronic sinus disease is still not fully understood. Macrophage mannose receptor (MMR), an innate pattern recognizing receptor, capable of phagocytosis of invaders and signal transduction for proinflammatory mechanisms, might be of importance in immune interactions in chronic sinus disease. OBJECTIVE: We examined the MMR in sinonasal airway mucosa to evaluate its possible role in chronic rhinosinusitis (CS) and nasal polyposis (NPs). METHODS: Surgical samples from patients with sinonasal disease were investigated with real-time RT-PCR for quantification of MMR mRNA expression, and the presence and location of MMR-positive cells was analysed by immunohistochemistry. RESULTS: Quantification of MMR mRNA showed a statistically significant higher expression in NPs compared to CS without NP and controls. Immunohistochemistry revealed expression of MMR in all tissue samples; however, in NP we found an enhanced positive cellular staining including cell aggregates. CONCLUSIONS: We could demonstrate for the first time that the expression of MMR is significantly upregulated in NP compared to patients with CS without NP or turbinate tissue of controls. Macrophages expressing MMR, accumulated in cell aggregates in NPs, play a possible key role in pathogen-macrophage interaction in NP disease.     

影像导航系统在鼻内镜手术中的应用

目的 总结影像导航技术在鼻内镜手术中的应用经验。方法 回顾性分析本院2007年5月至2010年9月采用美敦力Stealth Station LandmarX导航系统实施鼻内镜手术的患者33例（导航组）,包括慢性鼻窦炎、鼻息肉21例,孤立性蝶窦炎4例,额窦炎3例,鼻内翻性乳头状瘤2例,上颌窦骨瘤1例,鼻窦骨性纤维结构不良...     

The Anterior Ethmoidal “Genu”: A Newly Appreciated Anatomic Landmark for Endoscopic Sinus Surgery

Human sinonasal anatomy varies widely between patients, challenging surgeons operating in the sinuses. Ethmoid sinus anatomy is so variable it has been referred to as a labyrinth. Accordingly, reliable, consistent anatomic landmarks aid surgeons operating in this region. The goal of this investigation was to explore our observations and hypothesis that the ethmoidal bulla and the uncinate process are not entirely separate structures but rather attach, and the attachment could potentially provide a landmark for surgeons performing ethmoid and frontal recess surgery. Ethmoid sinus anatomy was studied in 57 sinonasal complexes through a variety of methods including gross anatomic dissection, endoscopic dissection and 3D CT stereoscopic imaging. The uncinate process and ethmoidal bulla were noted to fuse at the superior aspect of the hiatus semilunaris in 57/57 cases, forming a genu‐like feature in the anterior ethmoid. This consistent anatomic feature related closely to the frontal sinus drainage pathway, which drained medial to it in 44/57 (77%) cases. The anterior ethmoidal “genu” appears to be an excellent anatomic feature that surgeons can use during ethmoid and frontal recess surgery. High resolution 3D stereoscopic CT scan is capable of demonstrating sinonasal anatomy in a detailed fashion previously only achieved by cadaveric dissection. This technology can potentially allow for a virtual dissection of a patient's anatomy prior to surgery and could improve minimally invasive procedures and reduce complications. Clin. Anat. 32:534–540, 2019. © 2019 Wiley Periodicals, Inc.     

Treatment of nasal polyposis and chronic rhinosinusitis with fluticasone propionate nasal drops reduces need for sinus surgery

BACKGROUND: Steroid treatment is the mainstay of therapy for nasal polyps and rhinosinusitis. Oral steroids have considerable systemic side effects, and nasal sprays do not sufficiently reach the middle meatus, where polyps originate. Nasal drops might be a more useful formula to deliver steroids into the middle meatus. OBJECTIVE: We sought to investigate whether treatment with fluticasone propionate nasal drops (FPNDs) can reduce the need for surgery, as measured by signs and symptoms of nasal polyposis and chronic rhinosinusitis, in patients who are on the waiting list for functional endoscopic sinus surgery (FESS). METHODS: Fifty-four patients (28 male) with severe nasal polyposis, chronic rhinosinusitis, or both indicated for FESS were included in a 12-week, double-blind, placebo-controlled study. Use of intranasal steroid spray was stopped at least 4 weeks before randomization. Signs and symptoms were recorded before, during, and at the end of the study period. At the end of the study, a computed tomographic scan was performed, and the need for operation was reassessed by using a standardized scoring method. RESULTS: FESS was no longer required in 13 of 27 patients treated with FPNDs versus 6 of 27 in the placebo group (P < .05). Six patients from the placebo group dropped out versus 1 from the FPND group. Symptoms of nasal obstruction, rhinorrhea, postnasal drip, and loss of smell were reduced in the FPND group (P < .05). Peak nasal inspiratory flow scores increased significantly (P < .01). Polyp volume decreased in the FPND group (P < .05), and computed tomographic scores improved in both groups (P < .05). CONCLUSION: Treatment with FPNDs in patients indicated for FESS can reduce the need for surgery.     

Imaging of rhinosinusitis and its complications

Conventional plain-film radiographiy may be used as a screening method for various pathological conditions of the sinonasal cavities. However, CT scanning remains the study of choice for the imaging evaluation of acute and chronic inflammatory diseases of sinonasal cavities. MRI is superior to CT in differentiating inflammatory conditions from neoplastic processes. The most common complications of rhinosinusitis in children occur in the orbit. The information obtained from the CT scan and MRI, together with clinical findings, may be the best guidelines for clinical management and the mode of treatment. Although intracranial complications of sinusitis are relatively rare, prompt recognition of these disease states is important to prevent permanent neurological deficient or fatality. It is prudent to obtain MRI of the sinuses, orbits, and brain whenever extensive or multiple complications of sinusitis are suspected, in addition to CT scanning. Chronic rhinosinusitis is a clinical diagnosis, confirmed and staged with the CT scan of sinonasal cavities. Chronic inflammatory disease is often associated with mucosal thickening and sclerosis of the bone, particularly within the sinuses. Chronic extramucosal fungal sinusitis develops as a saprophytic growth in retained secretions in a sinus cavity. The imaging manifestations of chronic mycotic rhinosinusitis may be nonspecific or highly suggestive of the presence of fungal infection. The presence of diffuse increased attenuation within the paranasal sinuses and nasal cavity should be considered as chronic allergic hypersensitivity aspergillosis (chronic noninvasive aspergillosis) or chronic hyperplastic sinusitis and polyposis associated with desiccated, retained mucosal secretions. The MRI characteristics of fungal sinusitis depend on the stage of the disease.     

Histopathologic characteristics of inferior turbinate vs ethmoidal polypin chronic rhinosinusitis

It seems apparently that the 2 separate anatomical areas (nasal cavity and paranasal sinus mucosa) are indeed one single unit with an identical behavior during inflammatory process. Similar histopathologic evidence in long-term condition could emphasize on the concept of rhinosinusitis in patients with inflammatory paranasal sinus disease. Prospective study was performed on 50 consecutive patients with polyposis in 2 different groups, one with and the other without asthma. Inferior turbine and polyp with ethmoid sinus origin were selected to compare the histopathologic findings of the surgical specimens from the 2 sites (affected sinus vs apparently unaffected nose). The general degree of inflammation, epithelial thickening, and inflammatory cell count were measured. The degree of inferior turbinate inflammation correlated with that of the ipsilateral polyp of ethmoid sinus in both groups. In addition, the total inflammatory cell count was comparable. There was no statistically significant difference in total polymorphonuclear, lymphocyte, and eosinophil count between the 2 sites in each group (P > .05). The ethmoid sinus inflammation in polypoid chronic sinusitis is accompanied by a proportionate inferior turbinate inflammation, not only in the patients with asthma but also in those with isolated sinonasal polyposis.     

Imaging of rhinosinusitis and its complications: plain film, CT, and MRI

Conventional plain-film radiography may be used as a screening method for various pathological conditions of the sinonasal cavities. However, CT scanning remains the study of choice for the imaging evaluation of acute and chronic inflammatory diseases of sinonasal cavities. MRI is superior to CT in differentiating inflammatory conditions from neoplastic processes. The most common complications of rhinosinusitis in children occur in the orbit. The information obtained from the CT scan and MRI, together with clinical findings, may be the best guidelines for clinical management and the mode of treatment. Although intracranial complications of sinusitis are relatively rare, prompt recognition of these disease states is important to prevent permanent neurological deficit or fatality. It is prudent to obtain MRI of the sinuses, orbits, and brain whenever extensive or multiple complications of sinusitis are suspected, in addition to CT scanning. Chronic rhinosinusitis is a clinical diagnosis, confirmed and staged with the CT scan of sinonasal cavities. Chronic inflammatory disease is often associated with mucosal thickening and sclerosis of the bone, particularly within the sinuses. Chronic extramucosal fungal sinusitis develops as a saprophytic growth in retained secretions in a sinus cavity. The imaging manifestations of chronic mycotic rhinosinusitis may be nonspecific or highly suggestive of the presence of fungal infection. The presence of diffuse increased attenuation within the paranasal sinuses and nasal cavity should be considered as chronic allergic hypersensitivity aspergillosis (chronic noninvasive aspergillosis) or chronic hyperplastic sinusitis and polyposis associated with desiccated, retained mucosal secretions. The MRI characteristics of fungal sinusitis depend on the stage of the disease.     

Functional endoscopic sinus surgery improved asthma symptoms as well as PEFR and olfaction in patients with nasal polyposis

Background:  Nasal polyposis is a disease known to be associated with asthma. The management is anti-inflammatory, with topical and oral corticosteroids as the first-line treatment. The effect of surgical treatment on lower airway inflammation has not been sufficiently studied.
Aim:  The aim of this study is to investigate the effects of functional endoscopic sinus surgery (FESS) as well as fluticasone proprionate nasal drops (FPND) 400 μg b.i.d. on nasal and lower airway parameters in asthmatics with nasal polyposis.
Methods:  This was a prospective 21-week study of 68 patients with asthma and nasal polyposis, on the benefits of FESS on nasal '(butanol test, subjective olfaction, peak nasal inspiratory flow, congestion, rhinorrhoea, and polyp score)', and on the lower airway parameters (dyspnea, cough, mean daily peak expiratory flow rate (PEFR), and lung function tests). It also included a randomized, double-blind, placebo-controlled 14 weeks phase on FPND.
Results:  Functional endoscopic sinus surgery significantly improved mean asthma symptom scores and daily PEFR and all nasal parameters including subjective and objective olfaction tests. This is the first study that shows the benefits of FESS on butanol tests in patients with nasal polyposis. We found no significant difference between topical treatment with FPND or placebo in the nasal or lower airway variables.
Conclusion:  Functional endoscopic sinus surgery improved nasal and asthma symptoms in patients with nasal polyposis. Functional endoscopic sinus surgery could be considered early in the natural course of nasal polyposis with concomitant asthma, as well as a second-line treatment in nasal polyposis patients with a reduced sense of smell. The potential benefits of FPND 400 μg b.i.d. were probably overshadowed by FESS.     

Important research questions in allergy and related diseases: 3-chronic rhinosinusitis and nasal polyposis – a GA2LEN study

Chronic rhinosinusitis is one of the most common health care challenges, with significant direct medical costs and severe impact on lower airway disease and general health outcomes. The diagnosis of chronic rhinosinusitis (CRS) currently is based on clinical signs, nasal endoscopy and CT scanning, and therapeutic recommendations are focussing on 2 classes of drugs, corticosteroids and antibiotics. A better understanding of the pathogenesis and the factors amplifying mucosal inflammation therefore seems to be crucial for the development of new diagnostic and therapeutic tools. In an effort to extend knowledge in this area, the WP 2.7.2 of the GA²LEN network of excellence currently collects data and samples of 1000 CRS patients and 250 control subjects. The main objective of this project is to characterize patients with upper airway disease on the basis of clinical parameters, infectious agents, inflammatory mechanisms and remodeling processes. This collaborative research will result in better knowledge on patient phenotypes, pathomechanisms, and subtypes in chronic rhinosinusitis. This review summarizes the state of the art on chronic rhinosinusitis and nasal polyposis in different aspects of the disease. It defines potential gaps in the current research, and points to future research perspectives and targets.     

Paranasal sinus fungus ball: epidemiology, clinical features and diagnosis. A retrospective analysis of 173 cases from a single medical center in France, 1989-2002.

Over the last decade, we have observed a high frequency of Aspergillus rhinosinusitis in french medical centers. The epidemiological data, clinical presentations, radiology, mycology and histology results of 173 consecutive patients with paranasal sinus fungus balls who were admitted from 1989 to 2002 have been reviewed. The most common symptoms included purulent nasal discharges and nasal obstructions, with the maxillary sinus being the most common site of infection (152 cases, 87.8%). Computed tomography scans (CT scan) were performed in 92% (159/173) of the cases and heterogeneous opacities were observed in 132 patients (83%). Histology examinations were performed in all cases and proved positive in 162 patients. Fungi were recovered, mainly Aspergillus fumigatus, from samples of 50 patients, while specimens from the remaining 123 patients were negative. Since no specific clinical sign could be found, a diagnosis of fungus ball is frequently made after a long term symptomatic period. CT scan findings of metallic or calcified densities within an opacified sinus cavity are highly suggestive of a fungus ball, but mycological and histological studies are essential to confirm the diagnosis. Treatment consisted of functional endonasal sinus surgery and was successful in 172 out of 173 cases.