THE ROLE OF FUNGI IN

DISEASES OF THE NOSE AND

SINUSES
N O V I K A S H E R LY | 0 7 1 2 0 1 1 0 0 8 8

INTRODUCTION
An estimated 1.5 million fungal species inhabit
Earth
Normal respiration will routinely deposit fungal
ele- ments within the nose and paranasal sinuses.
Fungal rhinosinusitis and Noninvasive fungal
rhinosinusitis [ fungal colonization, fungal ball,
and allergic fungal rhinosinusitis (AFRS)]

IMMUNE STATUS AND FUNGAL

RHINOSINUSITIS
Immune dysfunction is the key factor
predisposing to fungal invasion of sinonasal
tissues
Suppression of the immune system, such as from
diabetes mellitus, chemotherapy, or
corticosteroids
In AFRS, chronic mucosal inflammation may be
mediated in part through IgE-mediated (type 1)
reactions to fungal species trapped in sinonasal
mucous

NON-INVASIVE FUNGAL RHINOSINUSITIS

Nasal crusts can become colonized by

macroscopic collections of fungi saprophytic
fungal colonization grow over time they
resemble a fungal ball impact surrounding
mucosa
Fungal ball : dense accumulation of fungal
elements within a single sinus
Maxillary (84%), sphenoid (14%), ethmoid and
frontal (rare)

NON-INVASIVE FUNGAL RHINOSINUSITIS

Symptoms : nasal congestion and facial pressure

CT-Scan : Hyperattenuated materials filling a
single sinus, often with associated calcifications
The diagnosis of a fungal ball is generally
confirmed during surgery when chalk-like
concretions are found within the sinus
Aspergillus fumigatus is the most common
fungal species

CT-SCAN OF FUNGAL BALL

NON-INVASIVE FUNGAL RHINOSINUSITIS

Management : Surgical opening of the natural

sinus ostium with evacuation of fungal debris
Antifungal antibiotics are not indicated in routine
cases

ALERGIC FUNGAL RHINOSINUSITIS

Symptoms : nasal congestion, facial pain/pressure,
nasal discharge, and diminished olfaction
Patients typically have an intact immune system
and often have a history of atopy, including
allergic rhinitis and/or asthma.

ALERGIC FUNGAL RHINOSINUSITIS

The Bent and Kuhn criteria for AFRS consist of the
following:
(1) nasal polyposis
(2) fungi on staining
(3) eosinophilic mucin without fungal invasion into
sinus
tissue
(4) type I hypersensitivity to fungi
(5) characteristic radiological findings with soft tissue
differential densities on CT scanning

CT-SCAN OF ALERGIC FUNGAL RHINOSINUSITIS

ALERGIC FUNGAL RHINOSINUSITIS

ALERGIC FUNGAL RHINOSINUSITIS

Management
Surgical therapy : remove polyps, open sinus ostia, and clear
eosinophilic fungal mucin, followed by aggressive medical
therapies
Medical therapy : oral and topical steroids, oral and topical
antifungals, leukotriene antagonists, and immunotherapy
Subcutaneous immunotherapy : beneficial

INVASIVE FUNGAL RHINOSINUSITIS

Acute Invasive Fungal Rhinosinusitis
Patients with poorly controlled diabetes mellitus and those
receiving chemotherapy, particularly bone marrow transplant
recipients
Chronic oral corticosteroids and those with human
immunodeficiency virus

INVASIVE FUNGAL RHINOSINUSITIS

Diagnosis criteria of Acute Invasive Fungal
Rhinosinusitis

disease presentation to occur in 4 weeks

Symptoms : nasal congestion, drainage, and facial pain/pressure
Progression : fever & epistaxis
Endoscopic findings are variable but classically include pale
and/or necrotic nasal mucosa

INVASIVE FUNGAL RHINOSINUSITIS

Spreading to
- orbit : proptosis, ophthalmoplegia, and decreased
visual acuity
- maxillary sinus : palatal and cheek necrosis
- across the skull base or along cranial nerves
via skull baseforamina : cranial nerve deficits
and mental status changes

CT-Scan of Acute Invasive Fungal Rhinosinusitis

INVASIVE FUNGAL RHINOSINUSITIS

Management of Acute Invasive Fungal
Rhinosinusitis
Surgical therapy : to remove necrotic, nonviable tissue.
Medical therapy : Intravenous antifungal antibiotics (liposomal
amphotericin B)

CHRONIC INVASIVE FUNGAL RHINOSINUSITIS

Chronic Invasive Fungal Rhinosinusitis

Invasive fungal infections with a time course of 12 weeks
diabetes, corticosteroid use, and human immunodeficiency virus
The diagnosis of chronic invasive fungal rhinosinusitis is
confirmed at surgery when histopathology shows fungal hyphae
infiltrating mucosa, blood vessels, or bone

T-Scan of Chronic Invasive Fungal Rhinosinusiti

CHRONIC INVASIVE FUNGAL RHINOSINUSITIS

Treatment of Chronic Invasive Fungal

Rhinosinusitis
Surgical removal of necrotic tissues and systemic antifungal
antibiotics
Tight glycemic control in diabetic patients
Discontinuation of corticosteroids

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