eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Sinusitis, Fungal: Workup

Author: Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University
Contributor Information and Disclosures

Updated: Apr 22, 2009

Workup

Laboratory Studies

  • Elevated total fungus-specific IgE concentrations are often found in patients with allergic fungal sinusitis. This is less common in patients with sinus mycetoma.

Imaging Studies

  • CT scanning of the paranasal sinuses in the coronal views is essential in the evaluation of patients in whom fungal sinusitis is suspected.5,6
  • MRI with enhancement may be helpful in assessing patients with allergic fungal sinusitis and in patients in whom invasive fungal sinusitis is suspected.6   
    • MRI may show low signal intensity, suggesting a fungal process versus a solid mass in allergic fungal sinusitis.
    • MRI is helpful in evaluating CNS spread in invasive fungal sinusitis.

Histologic Findings

In allergic fungal sinusitis, allergic mucin contains intact and degenerated eosinophils, Charcot-Leyden crystals, cellular debris, and sparse hyphae. The sinus mucosa has mixed cellular infiltrate of eosinophils, plasma cells, and lymphocytes. The mucus membrane is not invaded by fungi.

No allergic mucin is present in sinus mycetoma. However, the sinus contains dense material that consists of hyphae separate from but adjacent to the mucosa. The sinus mucosa is not invaded.

Histopathologic studies in acute invasive fungal sinusitis reveal hyphal invasion of the mucosa, submucosa, and blood vessels, including the carotid arteries and cavernous sinuses; vasculitis with thrombosis; hemorrhage; and tissue infarction.

Necrosis of the mucosa, submucosa, and blood vessels, with low-grade inflammation, is observed in chronic invasive fungal sinusitis.

Granuloma with multinucleated giant cells with pressure necrosis and erosion is observed in granulomatous invasive fungal sinusitis.

More on Sinusitis, Fungal

Overview: Sinusitis, Fungal
Workup: Sinusitis, Fungal
Treatment: Sinusitis, Fungal
Follow-up: Sinusitis, Fungal
Multimedia: Sinusitis, Fungal
References
Further Reading
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References

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  2. Scharf JL, Soliman AM. Chronic rhizopus invasive fungal rhinosinusitis in an immunocompetent host. Laryngoscope. Sep 2004;114(9):1533-5. [Medline].

  3. Siddiqui AA, Shah AA, Bashir SH. Craniocerebral aspergillosis of sinonasal origin in immunocompetent patients: clinical spectrum and outcome in 25 cases. Neurosurgery. Sep 2004;55(3):602-11; discussion 611-3. [Medline].

  4. Pant H, Schembri MA, Wormald PJ, Macardle PJ. IgE-mediated fungal allergy in allergic fungal sinusitis. Laryngoscope. Apr 8 2009;[Medline].

  5. Gamba JL, Woodruff WW, Djang WT, Yeates AE. Craniofacial mucormycosis: assessment with CT. Radiology. Jul 1986;160(1):207-12. [Medline].

  6. Manning SC, Merkel M, Kriesel K, Vuitch F, Marple B. Computed tomography and magnetic resonance diagnosis of allergic fungal sinusitis. Laryngoscope. Feb 1997;107(2):170-6. [Medline].

  7. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. Aug 2008;122(2 Suppl):S1-84. [Medline].

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  9. Corey JP, Romberger CF, Shaw GY. Fungal diseases of the sinuses. Otolaryngol Head Neck Surg. Dec 1990;103(6):1012-5. [Medline].

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  11. deShazo RD, O'Brien M, Chapin K, Soto-Aguilar M, Gardner L, Swain R. A new classification and diagnostic criteria for invasive fungal sinusitis. Arch Otolaryngol Head Neck Surg. Nov 1997;123(11):1181-8. [Medline].

  12. Gillespie MB, O'Malley BW Jr, Francis HW. An approach to fulminant invasive fungal rhinosinusitis in the immunocompromised host. Arch Otolaryngol Head Neck Surg. May 1998;124(5):520-6. [Medline].

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  16. Ochi JW, Harris JP, Feldman JI, Press GA. Rhinocerebral mucormycosis: results of aggressive surgical debridement and amphotericin B. Laryngoscope. Dec 1988;98(12):1339-42. [Medline].

  17. Press GA, Weindling SM, Hesselink JR, Ochi JW, Harris JP. Rhinocerebral mucormycosis: MR manifestations. J Comput Assist Tomogr. Sep-Oct 1988;12(5):744-9. [Medline].

  18. Sasama J, Sherris DA, Shin SH, Kephart GM, Kern EB, Ponikau JU. New paradigm for the roles of fungi and eosinophils in chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg. Feb 2005;13(1):2-8. [Medline].

  19. Schubert MS, Hutcheson PS, Graff RJ, Santiago L, Slavin RG. HLA-DQB1 *03 in allergic fungal sinusitis and other chronic hypertrophic rhinosinusitis disorders. J Allergy Clin Immunol. Dec 2004;114(6):1376-83. [Medline].

  20. Shin SH, Ponikau JU, Sherris DA, et al. Chronic rhinosinusitis: an enhanced immune response to ubiquitous airborne fungi. J Allergy Clin Immunol. Dec 2004;114(6):1369-75. [Medline].

  21. Sohail MA, Al Khabori MJ, Hyder J, Verma A. Allergic fungal sinusitis: can we predict the recurrence?. Otolaryngol Head Neck Surg. Nov 2004;131(5):704-10. [Medline].

  22. Washburn RG. Fungal sinusitis. Curr Clin Top Infect Dis. 1998;18:60-74. [Medline].

  23. Wise SK, Venkatraman G, Wise JC, DelGaudio JM. Ethnic and gender differences in bone erosion in allergic fungal sinusitis. Am J Rhinol. Nov-Dec 2004;18(6):397-404. [Medline].

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Further Reading

In 2008, the guidelines for the diagnosis and management of rhinitis were updated. 7

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Keywords

allergic fungal sinusitis, fungal sinusitis, indolent fungal sinusitis, mucormycosis, sinus fungus ball, sinus mycetoma, sinus infection, aspergillosis, Aspergillus species infection, Mucor species infection, Curvularia lunata infection, Aspergillus fumigatus infection, C lunata infection, A fumigatus infection, Bipolaris species infection, Drechslera species infection, dematiaceous fungi infection, Rhizopus species infection, Rhizomucor species infection, Absidia species infection, Cunninghamella species infection, Mortierella species infection, Saksenaea species infection, Apophysomyces species infection, Aspergillus flavus infection, A flavus infection

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Contributor Information and Disclosures

Author

Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University
Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Rhinologic Society
Disclosure: Nothing to disclose.

Medical Editor

Lanny Garth Close, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons
Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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