Adult Chronic Sinusitis and Its Complications

By G. Douglas Campbell Jr., MD, FCCP

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Medical Management in Special Situations

Fungal Sinusitis

The reported incidence of fungal sinusitis has increased in the past decade. Whether this is the result of improved diagnostic techniques, better awareness, increasing prevalence of immunosuppression, or all of the above is presently unknown. Because fungi can be recovered in nasal secretions of otherwise healthy individuals, deShazo⁴¹ states that fungal sinusitis can be accurately diagnosed only by histologic examination of material or tissue removed from the sinuses. The possibility of fungal sinusitis should be entertained in any patient with chronic sinusitis, particularly if the condition is resistant to medical management. The presence on CT scan of focal or diffuse areas of radiodensity and decreased T1- and T2-weighted signal intensity on MRI scanning is also suggestive of fungal sinusitis.⁴¹

The disease is divided into noninvasive (allergic fungal rhinosinusitis, mycetoma) and invasive fungal disease (acute invasive, chronic invasive, or granulomatous invasive fungal sinusitis). Management in almost all cases requires surgical intervention. In recent years, a better appreciation of the spectrum of sinus fungal involvement has developed, and the reader is referred to several review articles that discuss this disease in more complete detail.^41-44

In noninvasive disease, allergic fungal rhinosinusitis (AFS) can be thought of as the nasal equivalent of allergic bronchopulmonary aspergillosis. It normally presents in young, otherwise healthy patients as chronic rhinosinusitis, is frequently associated with polyposis, and involves multiple sinuses. It is estimated to account for 2 to 7% of all cases of chronic rhinosinisutis, and frequently the patient experiences asthma and has undergone several sinus surgeries. The sinus contents are described as looking like peanut butter or cottage cheese, but foul-smelling. AFS is frequently refractory to aggressive medical and surgical therapies. In one prospective study, the criteria proposed for optimizing the diagnosis of AFS included the presence of thick, viscous, often green mucus containing eosinophils; maxillary sinusitis; and the presence of specific IgE to Aspergillus fumigatis in the setting of chronic rhinosinusitis. Other immunoallergic tests, clinical findings, and radiographic findings were found to be of little help.⁴⁵ Sinus mycetomas are also noted to occur, mainly in immunocompetent individuals; they may involve any sinus but are frequently unilateral.⁴¹ The clinical presentation includes chronic rhinosinusitis, episodes of expelling gravel-like material nasally, headaches, facial pain, or seizures. These can be detected using coronal CT scanning. Eosinophilic mucin is not present unless the patient has concomitant AFS.

Acute (fulminant) invasive fungal sinusitis is seen primarily in immunosuppressed patients. It has been reported at autopsy in 22 to 28% of leukemic patients.²⁷ Aspergillus spp are most commonly reported, but other species include Candida, Rhizopus, and Mucor. Rhinosinusitis caused by Mucor spp has occasionally been noted in diabetic patients. Therapy is aggressive, with antifungal agents (especially amphotericin B) and antibiotics, treatment of underlying illness, and surgery with wide débridement. Chronic invasive fungal rhinosinusitis has only recently been reported, and to date this disease has mainly been seen in diabetic patients. Treatment has been similar to that for the acute form. Granulomatous invasive fungal sinusitis has largely been seen in immunocompetent North Americans. The most common fungus is Aspergillus flavus and treatment includes débridement and itraconazole.

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