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Classifications of Fungal Sinusitis

As mentioned before, sinusitis is defined as a disease state localized to any of the four paranasal sinus cavities. Within the context of these diseases, the subject of fungal sinusitis can be divided into four categories noninva-sive fungal masses (commonly called fungal balls), invasive sinusitis (with acute and chronic subtypes), chronic sinusitis, and allergic fungal rhinosinusitis (AFRS). The basis for these manifestations is dependent on the immune status of the host. Depending on whether the host is immunocompetent, immunocompromised, or is atopic, the type of disease and severity encountered can shift based on fluctuations in the host status.

Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is an inflammatory condition of the paranasal mucosa and nasal cavity that persists longer than 3 months. Typically medical or surgical treatments offer very little assistance to these patients, a reflection of the general morbidity caused by this disorder. There has been much controversy regarding the specific pathogenesis of CRS in the literature, as there are currently several competing theories as to what the mechanism of disease might be. Additionally, all studies have been analyzed with different parameters and with different methods, adding a great deal of discrepancy to the field, and not allowing all work to be directly comparable. Histopathology reveals inflammation of the mucosal lining, goblet cell hyperplasia, subepithelial edema, and mononuclear cell infiltration as hallmarks of CRS (Bachert et al., 2004). The major leukocyte affiliated with inflammation in CRS is the eosinophil, differing from the invasive forms of sinusitis where...

Allergic Fungal Rhinosinusitis

Allergic fungal rhinosinusitis (AFRS or AFS in the literature) is a hypersensitivity disease of the paranasal sinuses afflicting patients who are immunocompetent albeit with a history of atopy and allergic rhinitis to fungi. The disease process begins as the fungi become entrapped within the nasal cavity, presumably because of ostium obstruction or mucociliary disorder, and initiate a hypersensitive immune response. Just as with the other forms of fungal sinusitis, A. fumigatus is the most common etiological agent associated with AFRS (Table 1.1). and Hunsaker, 2002). However, as mentioned earlier, recent observations concerning patients who exhibit AFRS without increased IgE levels have questioned this mechanism, and has led to the suggestion of renaming AFRS to eosinophilic fungal rhinosinusitis to account for this disparity (Ponikau et al., 1999 Braun et al., 2003 Corradini et al., 2003). It is important to note that AFRS is most likely a multifac-toral process, though the decisive...

Invasive Fungal Sinusitis

Within invasive fungal sinusitis there are two distinct subtypes, acute and chronic. Acute sinusitis occurs in immunocompro-mised hosts (bone marrow transplant patients, HIV, etc.) and generally lasts for less than 4 weeks. In the literature it is commonly referred to as fulminant sinusitis, conveying the rapid disease progression and destruction affiliated with the infection (Ferguson, 2000a). Characteristically the disease progresses in a matter of days, with hyphal growth and extension pushing out of the sinus cavities and invading the surrounding mucosa, vascular system, and in severe cases, the cranium. Histological analysis reveals prominent hyphal extension, an influx of cellular exudates, and necrotic tissue surrounding the area. If patients presenting symptoms of acute invasive sinusitis fail to receive proper medical treatment, severe damage can occur to the nasal cavity, bone structure, and death can ensue (Fig. 1.2). In studies performed by Rudack on mucosa samples from...

Allergic rhinosinusitis

Allergic rhinosinusitis is a disorder expressed in the tissues of the nares and upper airway, manifested by local edema and inflammatory infiltration of the submucosa and mucosa, and associated with increased secretion of mucoid materials with accompanying inflammatory leukocytes. These processes lead to obstruction of airflow and of mucus drainage, and, therefore, may be complicated by postobstructive infectious complications. Allergic rhinosinusitis is a diagnosis made clinically, as there are no definitive objective tests available for routine clinical use to confirm this entity. There are two major forms of this disorder seasonal and perennial. Thus, it is a diagnosis based on history (often by questionnaire) and physical examination. In some epidemiological studies, the presence of allergy is confirmed by results of skin prick tests or in vitro allergy testing. The prevalence of this disorder varies widely in the literature, based upon the different sources of the data (i.e.,...

Sinusitis

Sinusitis is a better defined clinical condition. The pathogenesis of sinusitis is better understood nowadays after the importance of mucous transportation is realized. Sinusitis is usually unilaterally its symptoms are better appreciated in four levels 1. Primary (Level 1) symptoms of sinusitis are unusual as the sinuses have no specific function. However if the involved sinus becomes totally blocked, local pain and tenderness may occur as tension develops within the sinus. Acute sinusitis This commonly follows an URTI and presents acutely with fever local pain and tenderness over the involved sinus. Nasal symptoms may not be prominent. Nasal endoscopy reveals local congestion and pus may be seen streaming down from the diseased sinus. A pus swab should be taken for microbiological work-up and meanwhile the patient should be treated symptomatically with an analgesic and antipyretic. A 2-week course antibiotic with coverage for Gram-positive and Gramnegative organisms should be...

Cellular Anatomy and Physiology

Histological analysis of murine sinuses in a model of acute invasive fungal sinusitis. The arrow indicates hyphal A. fumigatus becoming invasive in the right maxillary cavity. Tissue invasion has occurred in addition to the necrotic tissue surrounding the mass. et ethmoid turbinates hp hard palate M maxillary sinus cavity s septum. Figure 1.2. Histological analysis of murine sinuses in a model of acute invasive fungal sinusitis. The arrow indicates hyphal A. fumigatus becoming invasive in the right maxillary cavity. Tissue invasion has occurred in addition to the necrotic tissue surrounding the mass. et ethmoid turbinates hp hard palate M maxillary sinus cavity s septum.

Complications And Prognosis

While sarcoidosis frequently pursues an unpredictable clinical course, its prognosis may correlate with specific types of disease onset and patterns of clinical manifestations. For example, acute onset of erythema nodosum with symptomatic bilateral hilar adenopathy usually has a self-limited course, while insidious onset of disease and extrapulmonary lesions are often followed by inexorable progression of pulmonary fibrosis (30). In the head and neck, complications of sarcoidosis include hearing loss, vestibular dysfunction, chronic sinusitis, infection, decreased visual acuity and blindness, hoarseness, upper respiratory obstruction, stridor, cranial nerve palsies, and pituitary dysfunction. The complications of the persistent ocular inflammation are described above, but it should be emphasized that sarcoidosis is a significant cause of blindness in the United States.

Physiology in Immunity

Since each variant of fungal sinusitis carries its own specific host response, further information regarding the role of nasal physiology in innate and adaptive immunity will be discussed with each of the different classifications of fungal sinusitis.

Endotracheal intubation

Nasotracheal intubation involves directing an ETT through the nasal passage and into the trachea. It can be done blindly or with a fiberoptic bronchoscope. It is done without the assistance of a laryngoscope and has been advocated by some to be the method of choice in cervical spinal cord injury where manipulation of the neck is to be avoided. Its primary indication is for rapid awake intubations (e.g. decompensat-ing COAD) where sedation would be undesirable. Other indications for nasotracheal intubation include elective oral surgery or limited mouth opening (e.g. temporo-mandibular joint (TMJ) dysfunction). It is contra-indicated in severe facial trauma to avoid placement of the tube through the cribiform plate, which has happened Advantages of nasotra-cheal intubation are ease of communication for the patient (and potentially less need of sedation), easier mouth care, avoidance of occlusion of the tube by biting down (good in pediatrics or head injury). Disadvantages are that a...

Noninvasive Fungal Masses Fungal Balls

Literature (though this is a misnomer as mycetomas technically represent superficial fungal infections on the feet) (Ferguson, 2000c). Fungal balls are noninvasive, non-immunogenic types of fungal sinusitis. Patients are immunocompetent and generally are neither atopic nor do they suffer from other disorders specific to the respiratory tract. The masses themselves are mycelial mats which can rest in the sinus cavities for months or years without any sort of tissue invasion. They are described as cheeselike, gritty, rubbery, or greasy masses that are easily discernible from the surrounding mucosa. They may be black or brownish in color, and often have a fetid odor associated with them. A small, localized inflammatory response may be seen, but the integrity of the nasal architecture is unchanged (Washburn, 1994). The benign mass is usually limited to the maxillary sinus cavity, with infections occurring infrequently in the sphenoid cavity as well. Symptoms include chronic nasal...

Imaging Studies in Mucormycosis

Maxillofacial CT scan is used for initial investigation in rhinocerebral infection. The CT scan may demonstrate ethmoid and sphenoid mucosal thickening or sinusitis as well as orbital or intracranial extension and is valuable in planning surgical debridement. Magnetic resonance imaging (MRI) with enhancement may be helpful in assessing patients with allergic fungal sinusitis and in patients in whom invasive fungal sinusitis is suspected. MRI is helpful in evaluating CNS spread in invasive fungal sinusitis and may be superior to CT in assessing the need for further surgical intervention. MRI additionally helps to define early vascular intracranial invasion before clinical signs develop.

Clinical Manifestations

Although these patients are at increased risk of infections due to pneumococcus and H. influenzae, there does not appear to be an increased risk of otitis media or sinusitis. Sickle cell patients do appear to be at increased risk for sleep-related breathing disorders. Sleep disturbance can be due to adenotonsillar hypertrophy or chronic lung disease.

Aspirin nsaid hypersensitivity

NSAID hypersensitivity tends to present in early adult years as rhinorrhea, nasal congestion, and hyposmia. In patients with asthma, NSAID hypersensitivity may develop concurrently or some years after the diagnosis of asthma has been established. In both groups, peripheral blood and tissue eosinophilia and pansinusitis with nasal polyposis are common. Approximately 10 of patients with steroid-dependent asthma have been found to be NSAID hypersensitive, whereas one-third of asthmatics with associated nasal polyposis and chronic sinusitis are sensitive to this class of drug. Although most normal patients tolerate these drugs, epidemiological studies suggest adverse reaction rates of up to 1 . In the vast majority of cases of NSAID hypersensitivity (asthma, rhinosinusitis, and polyposis), the pathogenetic mechanism behind the reaction is inhibition of the constitutively active enzyme COX-1 responsible for the generation of prostaglandins. In these instances, patients tolerate use of...

Mycobacterial Infections

Tuberculosis (TB, from Mycobacterium tuberculosis and or Mycobacterium bovis) is a major cause of morbidity and mortality in HIV disease. It usually presents as reactivation of a pulmonary primary focus, with a risk of 7 to 10 per year for HIV-infected persons regardless of CD4 lymphocyte count, versus 10 per lifetime for HIV-negative persons. There can be involvement of the lungs, central nervous system (CNS), or other organs, with rhinosinusitis, diffuse or localized (scrofula) lymphadenopathy, skin and mucosal ulcers, chronic otitis, and laryngeal involvement. Fever, chills, night sweats, and weight loss may be the presenting symptoms of any form of tuberculosis. Hemoptysis may be a symptom of laryngeal, tracheobronchial, or pulmonary disease. The clinical presentation becomes more atypical as the immunosuppression worsens pulmonary TB presenting with essentially normal chest X ray is not uncommon in CD4 counts of less than 50 cells mm3. TB can also coexist with other...

Arrival Of Pml Cases And An Electron Microscope

In the fall of 1962, a particularly stimulating consultation case was presented to me by the pathologist of a downtown Madison hospital. The patient, a 33-year-old woman with lupus erythematosus, had died after several weeks of progressive cerebellar disease. The slides showed a multifocal demyelinating disease with a most striking combination of giant tumor-like astrocytes and large numbers of oligodendrocytes with greatly enlarged nuclei deeply stained with hematoxylin. There were no distinct inclusion bodies as one sees with herpes viruses. I was fascinated and knew I had never seen this disease before. I showed the slides to a visiting neuropathologist and he, too, was at a loss. At that time I was in the midst of a very time-consuming experiment with a group of sophomore students. It involved the induction of brain tumors in chicken with Rous sarcoma virus. There was no time for a library search. However, I did show the slides to Dr. Chou, and to my utter surprise, and delight,...

Rhinocerebral Mucormycosis

RCM represents one-third to one-half of all cases of Zygomycosis. The process originates in the nose and paranasal sinuses following inspiration of fungal spores. It is estimated that 70 of the cases of rhinocerebral zygomycosis occur in the setting of DKA (7). Disease starts with symptoms consistent with sinusitis. Low-grade fever, dull sinus pain, drainage, Once the eye is infected, fungal disease can readily progress up the optic nerve, again gaining access to the CNS. Fungal invasion of the globe or ophthalmic artery leads to blindness. Angioinvasion is often seen and may result in systemically disseminated disease. Decidedly uncommon forms of rhinofacial disease published in the literature include isolated sinusitis and calcified fungal ball of the sinus. Early cases with rhinocerebral zygomycosis were almost uniformly fatal. There is still a high mortality rate with rhinocerebral disease, but curative interventions have been made with early diagnosis and aggressive surgical and...

Allergy and Dermatitis

There is clear evidence that otitis media with effusion is highly related to an allergic diathesis. When this converts to chronic draining otitis media, the allergic component would seem to still be relevant, although direct evidence is scant (17-19). Therefore, the surgeon must consider allergy evaluation, based on a patient history of other allergic diatheses, especially of the unified respiratory epithelium. Patients with chronic draining ear and allergic rhinitis, chronic rhinosinusitis, and asthma are strong candidates for allergy workup before contemplating surgical treatment.

Summary

Fungal sinusitis is an emerging family of fungal diseases, which has been thus far understudied. Though widely recognized in clinical setting and thoroughly reported in the literature, studies to corroborate these observations are yet to be done. In addition, few or no animal models have been developed to study the pathogenic process of fungal sinusitis. Future studies will need to explore the underlying host defense anomalies that predispose individuals to fungal infection of the sinuses and also examine the microbial factors that facilitate colonization, infection, and invasion.

Aspergillosis

Although Aspergillosis occurs almost only in severely immunocompromised patients, it is not AIDS defining. In the largest series described worldwide to date with 342 cases of invasive aspergillosis in HIV, almost all patients had less than 50 CD4 cells l (Mylonakis 1998). The main manifestation is in the lung (pneumonia, tracheobronchitis), but extrapulmonary infections can occur. These usually involve the CNS, but can principally be localized everywhere (Mylonakis 2000). Aspergillosis particularly occurs in HIV infected patients on long-term (too long) steroid treatment for another OI. Severe neutropenia (< 1,000 leucocytes) is another risk factor. Aspergillus fumigatus is by far the most frequent pathogen (> 90 ) followed by A. niger, A. terreus, A. flavus and A. nidulans. The patients, who are usually severely ill, complain of fever, cough, dyspnea and chest pain. Hemoptysis frequently occurs. Other manifestations include sinusitis or abscesses (kidneys, liver) (Hunt 2000). 4....

Irritant Gases

When the patient is exposed to a low-soluble gas, like phosgene, upper-airway signs and symptoms are not expected and observation is required because it may take as long as 24 hours for reactive airways dysfunction syndrome or pulmonary edema to develop. The development of reactive airways dysfunction syndrome (RADS) or asthma after exposure to irritant gases is the most common long-term complication. Early treatment with inhaled bronchodilators and inhaled corticosteroids is a well-proven treatment approach for those with symptoms and reversible bronchospasm. Reversible bronchospasm can be confirmed by documenting improvement in flow rates after treatment with either a peak flow meter or spirometry. Currently, no studies exist to determine whether early use of inhaled corticosteroids is a viable prophylactic strategy. However, the side effects of inhaled corticosteroids are minimal. Sinusitis may accompany lower-airway inflammation, and treatment with nasal corti-costeroids,...

Microsporidiosis

Diarrhea may be very severe and is usually watery, though not bloody. It is accompanied by abdominal pain, nausea and vomiting. Fever is almost always absent. Rarely, myositis, keratoconjunctivitis and sinusitis have been described. Infections of the biliary ducts are more frequent.

Preseptal cellulitis

This infection involves tissues anterior to the orbital septum and is sometimes preceded by trauma or sinusitis. Staphylococcus aureus, streptococci and Haemophilus influenzae are the common pathogens. Examination reveals eyelid erythema, swelling, warmth and tenderness, but there is neither proptosis nor restriction in ocular motility. Radiographs or CT scans may show signs of sinusitis or evidence of trauma. Systemic ampicillin combined with penicillinase-resistant antibiotics is the treatment of choice. Surgical treatment is indicated in unresponsive cases or for the treatment of associated sinusitis. While this condition in adults is relatively simple to treat, in infants and young children, this can constitute an emergency. The definition of the orbital septum in these cases is poor and it is not difficult for the infection to track through the septum into the tissues of the orbit. Since the orbit contains many vital structures, infection in this region can cause serious visual...

Cytologic Testing

Demonstration of fungal elements from cytologic preparations (i.e., sputa, inflammatory fluid aspirates from abscesses or sinusitis infection, and genitourinary and gynecologic specimens) may be difficult, due to the difficulty in extracting fungal elements from invaded tissues (8). Cultures of blood and cerebrospinal fluid (CSF) are negative. CSF, if inadvertently examined, may show an increased opening pressure, modest neutrophilic pleocytosis, normal or slightly elevated protein levels, or low glucose. In most cases, CSF study findings are normal. Smear and culture of sputum may be positive during cavitation of a lung lesion. Fine needle aspiration can yield a diagnosis, but should not preclude definitive therapy.

Definitions

Fungal sinusitis, when used loosely, can be a misleading term. It actually refers to a spectrum of fungal-associated diseases of the nose and paranasal sinuses, each with a unique presentation and management implications (Table 1). When communicating with Allergic fungal sinusitis rhinosinusitis CRS Abbreviation CRS, chronic rhinosinusitis. Abbreviation CRS, chronic rhinosinusitis. members of the health-care team, it is important to characterize the specific manifestation of fungal sinusitis (3). The definition of CRS set forth by the U.S. Food and Drug Administration is 12 weeks of persistent inflammation of the paranasal sinuses. As discussed in the introduction, investigators have proposed that eosinophilic fungal rhinosinusitis may account for the majority of cases of CRS. This is based on their finding of fungal elements in nearly all cases of CRS. While their hypothesis is currently being investigated, no one has conclusively demonstrated that fungi, and the immune system's...

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