Background
Fungal (rhino-) sinusitis encompasses a wide spectrum of immune and pathological responses, including invasive, chronic, granulomatous, and allergic disease. However, consensus on terminology, pathogenesis, and optimal management is lacking. The International Society for Human and Animal Mycology convened a working group to attempt consensus on terminology and disease classification.

/pdf/fungal-rhinosinusitis-a-categorization-and-definitional-llkbo2u47m.pdf

Fungal rhinosinusitis: A categorization and definitional schema addressing current controversies

Fungal infections are a subset of infectious processes that an otolaryngologist is required to be familiar with. They can be encountered in otology, rhinology and head and neck surgery. The presence of fungal rhinosinusitis is well recognised by otolaryngologists, but the classifications and appropriate management are not so well understood. The prevalence of fungal sinus disease is thought to be have been increasing in recent decades There is speculation that this may be due to increased awareness, antibiotic overuse and increased use of immunosuppressant medications. Added to this, there has been a large amount published on the role of fungi as a causative organism in chronic rhinosinusitis. Given the importance of fungal rhinosinusitis in clinical practice, we aim to review the classification and current management strategies based on up-to-date literature.

/pdf/invasive-and-non-invasive-fungal-rhinosinusitis-a-review-and-5ailv2t04z.pdf

Invasive and Non-Invasive Fungal Rhinosinusitis—A Review and Update of the Evidence

Objectives/Hypothesis:

Herein we present our experience in the management of fungus ball (FB) of the paranasal sinuses. Preoperative imaging strategy and findings, surgical technique, and pathologic and microbiologic results are discussed.



Study Design:

Retrospective chart review of patients with FB of the paranasal sinuses who underwent endoscopic surgery at the Department of Otorhinolaryngology of the University of Brescia, Italy.



Methods:

From January 1990 to December 2006, 160 patients with sinonasal fungus ball were treated with a purely endoscopic approach. All patients underwent preoperative computed tomography (CT) and/or magnetic resonance (MR) imaging; an endo-oral dental x-ray or orthopantomography and odontological evaluation were also performed in patients with maxillary sinus localization. All removed material was sent for pathologic and microbiologic evaluation. All patients were prospectively followed with endoscopic control every 2 months during the first postoperative year and subsequently every 6 months.



Results:

The patient cohort included 118 females and 42 males, with an age from 19 to 85 years (mean, 52.7 years). FB was located in the maxillary sinus in 135 (84.4%) patients; in two cases both sinuses were affected. Sphenoid and ethmoid involvement was observed in 23 (14.4%) and 1 (0.6%) patients, respectively. Simultaneous ethmoid and sphenoid involvement was found in one (0.6%) case. In all patients complete removal of fungal debris was obtained through wide sinusotomy. No recurrence was observed.



Conclusions:

Endoscopic surgery is a safe and effective treatment for paranasal sinuses FB. A proper imaging study by MR and/or CT can address diagnosis, which is based upon detection of fungal hyphae at histology. Laryngoscope, 2009

Fungus ball of the paranasal sinuses: experience in 160 patients treated with endoscopic surgery.

Fungal Rhinosinusitis (FRS) is a well known entity, but only in more recent times have the types of FRS been more fully defined. In this study, we evaluate the diagnosis of FRS in a single medical center. Cases were divided into 2 main categories, non-invasive and invasive. Non-invasive FRS included fungus ball (FB) and allergic fungal rhinosinusitis (AFRS). Invasive FRS included acute invasive fungal rhinosinusitis (AIFRS), chronic invasive fungal rhinosinusitis (CIFRS), and chronic invasive granulomatous fungal rhinosinusitis (CGFRS). Fungal culture data, if available was reviewed. 400 patients with FRS were identified. 87.25% were non-invasive (45% AFRS, 40% FB, and 2% combined AFRS and FB and 12.5% were invasive 11% AIFRS 1.2% CIFRS 0.5% CGFRS. One patient (0.25%) had combined FB/CGFRS. Aspergillus sp. or dematiaceous species were the most common fungi isolated in AFS while Aspergillus sp. was most common in FB and AIFRS. In our experience, most FRS is non-invasive. In our patient population, invasive FRS is rare with AIFRS representing >90% of cases. Culture data supports that a variety of fungal agents are responsible for FRS, but Aspergillus sp. appears to be one of the most common organisms in patients with FRS.

/pdf/fungal-rhinosinusitis-a-retrospective-microbiologic-and-4k6677nfz1.pdf

Fungal Rhinosinusitis: A Retrospective Microbiologic and Pathologic Review of 400 Patients at a Single University Medical Center

The role of Toll-like receptor 9 (TLR9) in antifungal responses in the immunodeficient and allergic host is unclear. We investigated the role of TLR9 in murine models of invasive aspergillosis and fungal asthma. Neutrophil-depleted TLR9 wild-type (TLR9+/+) and TLR9-deficient (TLR9−/−) mice were challenged with resting or swollen Aspergillus fumigatus conidia and monitored for survival and lung inflammatory responses. The absence of TLR9 delayed, but did not prevent, mortality in immunodeficient mice challenged with resting or swollen conidia compared to TLR9+/+ mice. In a fungal asthma model, TLR9+/+ and TLR9−/− mice were sensitized to soluble A. fumigatus antigens and challenged with resting or swollen A. fumigatus conidia, and both groups of mice were analyzed prior to and at days 7, 14, and 28 after the conidium challenge. When challenged with resting conidia, TLR9−/− mice exhibited significantly lower airway hyper-responsiveness compared to the TLR9+/+ groups. In contrast, A. fumigatus-sensitized TLR9−/− mice exhibited pulmonary fungal growth at days 14 and 28 after challenge with swollen conidia, a finding never observed in their allergic wild-type counterparts. Increased fungal growth in allergic TLR9−/− mice correlated with markedly decreased dectin-1 expression in whole lung samples and isolated dendritic cell populations. Further, whole lung levels of interleukin-17 were lower in allergic TLR9−/− mice compared to similar TLR9+/+ mice. Together, these data suggest that TLR9 modulates pulmonary antifungal immune responses to swollen conidia, possibly through the regulation of dectin-1 expression.

https://iai.asm.org/content/iai/77/1/108.full.pdf

Toll-Like Receptor 9 Modulates Immune Responses to Aspergillus fumigatus Conidia in Immunodeficient and Allergic Mice

Over the last decade, we have observed a high frequency of Aspergillus rhinosinusitis in french medical centers. The epidemiological data, clinical presentations, radiology, mycology and histology results of 173 consecutive patients with paranasal sinus fungus balls who were admitted from 1989 to 2002 have been reviewed. The most common symptoms included purulent nasal discharges and nasal obstructions, with the maxillary sinus being the most common site of infection (152 cases, 87.8%). Computed tomography scans (CT scan) were performed in 92% (159/173) of the cases and heterogeneous opacities were observed in 132 patients (83%). Histology examinations were performed in all cases and proved positive in 162 patients. Fungi were recovered, mainly Aspergillus fumigatus, from samples of 50 patients, while specimens from the remaining 123 patients were negative. Since no specific clinical sign could be found, a diagnosis of fungus ball is frequently made after a long term symptomatic period. CT scan findings of metallic or calcified densities within an opacified sinus cavity are highly suggestive of a fungus ball, but mycological and histological studies are essential to confirm the diagnosis. Treatment consisted of functional endonasal sinus surgery and was successful in 172 out of 173 cases.

Paranasal sinus fungus ball: epidemiology, clinical features and diagnosis. A retrospective analysis of 173 cases from a single medical center in France, 1989-2002.

Resume Objectif. – Decrire les differentes pathologies fongiques rhinosinusiennes. Resultats. – L’interaction entre les agents fongiques et les cavites nasosinusiennes se traduit par de nombreuses affections dont le tableau clinique varie selon l’agent fongique et le statut immunitaire du patient. L’agent fongique peut etre soit dans le mucus ou sur la muqueuse pour les formes non invasives. Il infiltre les tissus (os, vaisseaux, muqueuse) dans les formes invasives). Les caracteristiques diagnostiques et therapeutiques de ces pathologies sont decrites dans l’article. Les recentes formes de sinusites fongiques a eosinophiles sont egalement discutees.

Agent fongique et pathologie rhinosinusienne

Resume La pathologie rhinosinusienne fongique est bien connue, en particulier, les formes invasives et les formes non invasives (balle fongique, rhinites allergiques IgE dependante). Plus recemment une nouvelle entite a ete decrite : la rhinosinusite fongique allergique (RFA). Depuis les premieres descriptions, dont les criteres diagnostiques sont proches de l’aspergillose bronchopulmonaire, de nombreux travaux concernant la rhinosinusite chronique et la polypose ont ete publies. Dans ces observations, le role des agents fongiques trouves dans un mucus visqueux, riche en eosinophile, reste indetermine. Cet article fait le point sur les donnees recentes concernant ces pathologies en analysant les elements diagnostiques et la physiopathologie proposes dans la litterature. Les criteres a retenir en faveur d’un rhinosinusite fongique allergique sont precises. Les travaux recents avec le traitement antifongique intranasal sont analyses. Bien que toutes ces publications aient augmente la confusion, le diagnostic de RFA demeure probable pour certains patients lorsque sont reunis les elements immuno-allergologiques communs a toutes les pathologies allergiques.

Est-ce que l’allergie rhinosinusienne fongique existe ?

Nous rapportons trois observations de patients adultes, non immunodeprimes, traites pour une rhinosinusite due a des champignons filamenteux opportunistes du genre Scedosporium. Dans ce contexte, il est rare d'isoler ce champignon dont la pathologie est ici tres semblable a celle de la rhinosinusite aspergillaire. L'exerese chirurgicale a permis leur guerison en l'absence de traitement antifongique.

Rhinosinusite à Scedosporium apiospermum chez des patients non immunodéprimés : A propos de 3 cas

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Papers

Paranasal sinus fungus ball: epidemiology, clinical features and diagnosis. A retrospective analysis of 173 cases from a single medical center in France, 1989-2002.

Agent fongique et pathologie rhinosinusienne

Est-ce que l’allergie rhinosinusienne fongique existe ?

Rhinosinusite à Scedosporium apiospermum chez des patients non immunodéprimés : A propos de 3 cas