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Fungal Sinusitis Workup

  • Author: Hassan H Ramadan, MD, MSc; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: May 04, 2016
 

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.

Using enzyme-linked immunosorbent assays, one study examined the sinonasal tissue and secretions in patients with chronic rhinosinusitis for the presence of mycotoxins (ie, aflatoxin, deoxynivalenol, zearalenone, ochratoxin, and fumonisin) to determine their possible role, if any, in chronic rhinosinusitis. No mycotoxins were found, except ochratoxin in 4 of 18 samples. The clinical significance of these results has not been determined.[7]

A study by Payne et al of 41 patients with acute invasive fungal rhinosinusitis reported that predictive variables for the disease include an absolute neutrophil count below 500/μL (sensitivity of 78%), abnormalities of the septal mucosa (specificity of 97%), and necrosis and mucosal abnormalities of the middle turbinate (specificities of 97% and 88%, respectively).[8]

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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.[9, 10]  Middlebrooks et al devised a seven-variable, computed tomography (CT) scan–based diagnostic model for acute invasive fungal rhinosinusitis. They reported that an abnormality associated with one of the model’s variables—which consist of periantral fat, bone dehiscence, orbital invasion, septal ulceration, the pterygopalatine fossa, the nasolacrimal duct, and the lacrimal sac—has a positive predictive value of 87%, a negative predictive value of 95%, a sensitivity of 95%, and a specificity of 86%, while the involvement of two variables gives the model a specificity of 100% and a positive predictive value of 100%.[11]

MRI with enhancement may be helpful in assessing patients with allergic fungal sinusitis and in patients in whom invasive fungal sinusitis is suspected.[10]  MRI may show low signal intensity, suggesting a fungal process versus a solid mass in allergic fungal sinusitis. It is also helpful in evaluating CNS spread in invasive fungal sinusitis.

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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.

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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 School of Medicine

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, American Rhinologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

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 Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, New York Academy of Medicine

Disclosure: Nothing to disclose.

References
  1. Hussain S, Salahuddin N, Ahmad I, Salahuddin I, Jooma R. Rhinocerebral invasive mycosis: occurrence in immunocompetent individuals. Eur J Radiol. 1995 Jul. 20(2):151-5. [Medline].

  2. Scharf JL, Soliman AM. Chronic rhizopus invasive fungal rhinosinusitis in an immunocompetent host. Laryngoscope. 2004 Sep. 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. 2004 Sep. 55(3):602-11; discussion 611-3. [Medline].

  4. Lu-Myers Y, Deal AM, Miller JD, et al. Comparison of Socioeconomic and Demographic Factors in Patients with Chronic Rhinosinusitis and Allergic Fungal Rhinosinusitis. Otolaryngol Head Neck Surg. 2015 Apr 27. [Medline].

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

  6. Gupta R, Gupta AK, Patro SK, et al. Allergic fungal rhino sinusitis with granulomas: A new entity?. Med Mycol. 2015 May 30. [Medline].

  7. Lieberman SM, Jacobs JB, Lebowitz RA, Fitzgerald MB, Crawford J, Feigenbaum BA. Measurement of Mycotoxins in Patients with Chronic Rhinosinusitis. Otolaryngol Head Neck Surg. 2011 Mar 31. [Medline].

  8. Payne SJ, Mitzner R, Kunchala S, Roland L, McGinn JD. Acute Invasive Fungal Rhinosinusitis: A 15-Year Experience with 41 Patients. Otolaryngol Head Neck Surg. 2016 Apr. 154 (4):759-64. [Medline].

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

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

  11. Middlebrooks EH, Frost CJ, De Jesus RO, Massini TC, Schmalfuss IM, Mancuso AA. Acute Invasive Fungal Rhinosinusitis: A Comprehensive Update of CT Findings and Design of an Effective Diagnostic Imaging Model. AJNR Am J Neuroradiol. 2015 Apr 16. [Medline].

  12. Mehta R, Panda NK, Mohindra S, et al. Comparison of efficacy of amphotericin B and itraconazole in chronic invasive fungal sinusitis. Indian J Otolaryngol Head Neck Surg. 2013 Aug. 65:288-94. [Medline]. [Full Text].

  13. Green KK, Barham HP, Allen GC, Chan KH. Prognostic Factors in the Outcome of Invasive Fungal Sinusitis in a Pediatric Population. Pediatr Infect Dis J. 2016 Apr. 35 (4):384-6. [Medline].

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

  15. Anselmo-Lima WT, Lopes RP, Valera FC, Demarco RC. Invasive fungal rhinosinusitis in immunocompromised patients. Rhinology. 2004 Sep. 42(3):141-4. [Medline].

  16. Gosepath J, Mann WJ. Role of fungus in eosinophilic sinusitis. Curr Opin Otolaryngol Head Neck Surg. 2005 Feb. 13(1):9-13. [Medline].

  17. 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. 2005 Feb. 13(1):2-8. [Medline].

  18. 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. 2004 Dec. 114(6):1376-83. [Medline].

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

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

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

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