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

Sinusitis, Fungal

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

Introduction

Fungal infections of the sinuses have recently been blamed for causing most cases of chronic rhinosinusitis. The evidence, though, is still controversial. Most fungal sinus infections are benign or noninvasive, except when they occur in individuals who are immunocompromised. Several reports are available that have shown invasive fungal infections in immunocompetent individuals.1,2,3

Distinguishing invasive disease from noninvasive disease is important because the treatment and prognosis are different for each. Noninvasive disease has 2 varieties of presentations, and invasive disease has 3 varieties of presentations. This article reviews all 5 varieties. For excellent patient education resources, see eMedicine's Headache Center. Also, visit eMedicine's patient education article, Sinus Infection.

Axial CT scan of sinuses shows a right fungal max...

Axial CT scan of sinuses shows a right fungal maxillary sinusitis with an expanding mass (possibly aspergillosis).

Axial CT scan of sinuses shows a right fungal max...

Axial CT scan of sinuses shows a right fungal maxillary sinusitis with an expanding mass (possibly aspergillosis).


History of the Procedure

Fungal infections of the paranasal sinuses are uncommon and usually occur in individuals who are immunocompromised. However, recently, the occurrence of fungal sinusitis has increased in the immunocompetent population.

The most common pathogens are from Aspergillus and Mucor species. Aspergillosis can cause noninvasive or invasive infections. Invasive infections are characterized by dark, thick, greasy material found in the sinuses. Invasive infections can cause tissue invasion and destruction of adjacent structures (eg, orbit, CNS). Noninvasive infections cause symptoms of sinusitis, and the sinus involved is opacified on radiographic studies. Routine cultures from the sinuses rarely demonstrate the fungus. However, the fungus is usually suspected upon reviewing the CT scan result and is detected on removal of the secretions from the sinus.

Problem

Fungal infections of the paranasal sinus can manifest as 2 distinct entities.

The more serious infection commonly occurs in patients with diabetes or in individuals who are immunocompromised and is characterized by its invasiveness, tissue destruction, and rapid onset. Early detection and treatment are vital for these infections because of the high mortality rate.

Noninvasive infections are chronic and are usually treated for extended periods as chronic sinusitis before the condition is recognized.

Etiology

Noninvasive fungal sinusitis

Two forms are described in this category: allergic fungal sinusitis and sinus mycetoma/ball.

Most commonly, Curvularia lunata, Aspergillus fumigatus, and Bipolaris and Drechslera species cause allergic fungal sinusitis.

A fumigatus and dematiaceous fungi most commonly cause sinus mycetoma.

Invasive fungal sinusitis

Invasive fungal sinusitis includes the acute fulminant type, which has a high mortality rate if not recognized early and treated aggressively, and the chronic and granulomatous types.

Saprophytic fungi of the order Mucorales, including Rhizopus, Rhizomucor, Absidia, Mucor, Cunninghamella, Mortierella, Saksenaea, and Apophysomyces species, cause acute invasive fungal sinusitis.

A fumigatus is the only fungus associated with chronic invasive fungal sinusitis.

Aspergillus flavus exclusively has been associated with granulomatous invasive fungal sinusitis.

Pathophysiology

Allergic fungal sinusitis

Allergic rhinitis is prevalent in this group and is considered to be the trigger mechanism behind allergic fungal sinusitis. Patients are immunocompetent and often have asthma, eosinophilia, and elevated total fungus-specific immunoglobulin E (IgE) concentrations.4

Surgery reveals greenish black or brown material (ie, allergic mucin), which has the consistency of peanut butter mixed with sand and glue. Allergic mucin and polyps may form a partially calcified expansile mass that obstructs sinus drainage. Growth of the mass may cause pressure-induced erosion of bone, rupture of sinus walls, and occasional leakage of the sinus contents into the orbit or brain.

Sinus mycetoma

This condition is usually unilateral and involves the maxillary sinus. Mucopurulent, cheesy, or claylike material is present at the time of surgery. Patients with sinusitis mycetoma are immunocompetent. Allergic conditions and fungus-specific IgE are less common.

Acute invasive fungal sinusitis

Acute invasive fungal sinusitis results from a rapid spread of fungi through vascular invasion into the orbit and CNS. It is common in patients with diabetes and in patients who are immunocompromised and has been reported in immunocompetent individuals. Typically, patients with acute invasive sinusitis are severely ill with fever, cough, nasal discharge, headache, and mental status changes. They usually require hospitalization.

Chronic invasive fungal sinusitis

Chronic invasive fungal sinusitis is a slowly progressive fungal infection with a low-grade invasive process and usually occurs in patients with diabetes.

Orbital apex syndrome, which is characterized by a decrease in vision and ocular immobility due to a mass in the superior portion of the orbit, is usually associated with this condition.

Granulomatous invasive fungal sinusitis

This condition has been reported almost exclusively in immunocompetent individuals from North Africa. Generally, proptosis is associated with granulomatous invasive fungal sinusitis.

Presentation

Allergic fungal sinusitis

Patients present with symptoms of chronic sinusitis, which may include facial pressure, headache, nasal stuffiness, discharge, and cough. The condition should be suspected in individuals with intractable sinusitis and nasal polyposis.

Some patients may present with proptosis or eye muscle entrapment. These patients usually have atopy and have had multiple surgeries by the time of diagnosis. CT scanning of the sinuses reveals opacification with concretions and/or calcifications.

Sinus mycetoma

Presentation of patients with sinus mycetoma is similar to that of patients with sinusitis. Examination may reveal polyposis with evidence of sinusitis, mainly on one side. The main report is blowing of gravel-like material from the nose. Usually, sinus mycetoma is found accidentally on CT scanning of the sinuses.

Acute invasive fungal sinusitis

Patients are usually hospitalized and are very sick with fever, cough, nasal discharge, headache, and mental status changes. A high index of suspicion for early diagnosis is critical, especially in individuals who are immunocompromised.

Signs and symptoms include dark ulcers on the septum, turbinates, or palate. In the late stages, signs and symptoms of cavernous sinus thrombosis are present.

Chronic invasive fungal sinusitis

Patients present with symptoms of long-standing sinusitis. Symptoms are usually not acute, and fever and mental status changes are absent.

Orbital apex syndrome, which is characterized by a decrease in vision and ocular immobility due to a mass in the superior portion of the orbit, is usually associated with this condition.

Nasal examination findings can be minimal. However, findings from the eye examination can be positive.

Granulomatous invasive fungal sinusitis

Patients present with symptoms of chronic sinusitis associated with proptosis. Examination of the nasal cavity can be nonrevealing. However, findings from the eye examination are usually impressive.

Indications

The treatment of choice for all types of fungal sinusitis is surgical (see Surgical therapy).

Relevant Anatomy

See Surgical therapy.

Contraindications

All forms of fungal sinusitis require surgical treatment. The only contraindications to surgical management relate to the general condition of the patient. Before surgery is recommended, risks and benefits of the surgical procedure should be weighed against the risks of general anesthesia.

More on Sinusitis, Fungal

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

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].

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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].

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  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].

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  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].

Further Reading

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

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

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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