FUNGAL SINUSITIS

FUNGAL SINUSITIS

FUNGAL SINUSITIS contributed by :- Dr. nafisa parveen Jawaharlal nehru medical college Aligarh muslim university aligarh

For more ppts., visit www.nayyarENT.com

25-07-2012www.nayyarENT.com1IntroductionFungi are ubiquitousImmune system keeps organisms suppressedMost infections are benign, non-invasiveImmunocompromised higher risk of invasive disease

25-07-2012www.nayyarENT.com2Basic Mycology20,000 1.5 million fungal speciesFew dozen species cause human infectionForms: yeast or moldYeastUnicellularReproduce asexually by buddingPseudohyphae when bud doesnt detach from yeastMoldMulticellularGrow by branching hyphae25-07-2012www.nayyarENT.com3Basic MycologySporeReproductive structure produced in unfavorable conditions

Withstand many adverse conditionsFavorable environment growth

Inhalation of spores most common way fungi infiltrate sinuses to cause disease25-07-2012www.nayyarENT.com4Basic MycologyMicroscopic Appearance of Specific Fungi

AspergillusSeptated hyphae with branching at 45

MucromycosisNonseptated hyphae with branching at 9025-07-2012www.nayyarENT.com5Classification of InfectionNon-invasiveSaprophytic fungal infectionSinus fungal ball (mycetoma)Allergic fungal sinusitisNonallergic eosinophilic fungal sinusitis

InvasiveAcute fulminant invasive fungal sinusitisChronic invasive fungal sinusitisGranulomatous invasive fungal sinusitis25-07-2012www.nayyarENT.com6Saprophytic Fungal InfestationVisible growth of fungus on mucus crusts without invasionMinimal to no sinonasal symptomsAfter sinonasal surgeryDiagnosisEndoscopic visualization of crusts with fungiTreatmentRemoval of crustsNasal saline irrigationsWeekly nasal endoscopy with removal of crusts until disease process resolves25-07-2012www.nayyarENT.com7Sinus Fungal Ball (Mycetoma)Sequestration of fungal elements within a sinus without invasion or granulomatous changesInhaled spores grow while evading host immune system (no invasion)Aspergillus most common speciesMaxillary sinus most often involved (70-80% of cases)

25-07-2012www.nayyarENT.com8Sinus Fungal Ball (Mycetoma)ClinicallySymptoms due to mass effect and sinus obstructionPresents similar to rhinosinusitisCongestion, facial pain, headache, rhinorrhea

Physical examinationMild to minimal mucosal inflammationPolyps in 10% of cases25-07-2012www.nayyarENT.com9Sinus Fungal Ball (Mycetoma)DiagnosisCT ScanSingle sinus in 59-94% of cases (maxillary)Complete or subtotal opacification of sinusRadiodensities within the opacificationsDue to increased heavy metal contentBony sclerosis; destruction is rare (3.6-17% of cases)Biopsy = fungal elements25-07-2012www.nayyarENT.com10Sinus Fungal Ball (Mycetoma)TreatmentComplete surgical removal of fungal ballIrrigation of involved sinusesAntifungal therapyOnly if patient is high risk for invasive disease (very rare)Severely immunocompromisedContinued recurrence of disease despite proper medical/surgical managementConsider topical antifungal irrigation first and then systemic therapy if no improvement25-07-2012www.nayyarENT.com11Allergic Fungal SinusitisFungal colonization resulting in allergic inflammation without invasionIgE mediated response to fungal proteinSymptoms:Nasal obstruction (gradual)RhinorrheaFacial pressure/painSneezing, watery/itchy eyesPeriorbital edema25-07-2012www.nayyarENT.com12Allergic Fungal SinusitisDiagnostic Criteria

Eosinophlic mucinNasal polyposisRadiographic findingsImmunocompetanceAllergy to fungi25-07-2012www.nayyarENT.com13Allergic Fungal SinusitisEosinophilic MucinPathognemonicThick, tenacious and highly viscousTan to brown or dark green in appearanceMicroscopic examinationBranching fungal hyphaeSheets of eosinophilsCharcot-Leyden crystalsBreakdown of cells by enzymes produced by eosinophilsSlender and pointed at each endPair of hexagonal pyramids joined at bases25-07-2012www.nayyarENT.com14Allergic Fungal SinusitisRadiographic findingsCTUnilateral (78% of cases)Sinus expansionBone destruction in 20% of casesMore often in advanced or bilateral diseaseDouble DensitiesHeterogeneity of signal increased heavy metal content (iron and manganese) and calcium salts

25-07-2012www.nayyarENT.com15Allergic Fungal SinusitisRadiographic findings

MRIVariable signal intensity on T1 (usually hyperintense)

T2 hypointense central portion (low water content of mucin) with peripheral enhancement due to edema25-07-2012www.nayyarENT.com16Allergic Fungal SinusitisPathogenesis-mucociliary transport disruption,dryness or a large inoculum ,the mold spore may not be clearedgermination increases antigenicitygreater production of allergic mucinfungus continues to grow(positive feedback loop)more allergic mucinresists clearance by normal mucociliary actioninflammatory cytokine milieu promotes the growth of nasal polyps.Associated with HLA-DR2,HLA-DR5 and HLA-DQB1*03IgE levels>1000IU/ml

25-07-2012www.nayyarENT.com17Allergic Fungal SinusitisTreatmentSurgicalRemove all mucin and nasal polyp , usually endoscopically.Mucin is tenacious,the microdebriders can facilitate the removalProvide permanent drainage and ventilation of affected sinusesSystemic +/- topical steroidsSystemic steroids decrease rate of recurrenceCourse can range from 2-4 weeksSchubert showed that longer courses had better results, but more side effects0.5mg/kg Prednisone starting dose and taper over 2-4weeks25-07-2012www.nayyarENT.com18Allergic Fungal SinusitisImmunotherapyDecrease recurrenceAlleviate need for steroidThe humanized monoclonal antibody to the Fc portion of IgE, OMALIZUMAB,approved for severe allergic asthma.Van der ent and coworkers reported ABPA showed dramatic and rapid response to a single dose of omalizumab.

25-07-2012www.nayyarENT.com19Allergic Fungal SinusitisOther modalitiesAntibacterial therapiespresence of a bacterial superantigen.Calcineurin inhibitors(picrolimus and tacrolimus)prevent superantigen stimulation.Saline lavagebefore topical steroidAntifungalno study till date for AFS ,ABPA ,the antifungal itraconazole 200mg bd for 16wks was shown significant improvement in a randomized, placebo-controlled multicenter study.25-07-2012www.nayyarENT.com20Nonallergic eosinofilic fungul sinusitisProposed by Ponikau and collegues in the late 1990s.Treatment irrigation of nose with 20ml of amphotericinB twice a day for 4 months.25-07-2012www.nayyarENT.com21Acute Fulminant Invasive Fungal SinusitisPatient populationMost often compromised immune systemDM, AIDS, hematologic malignancies, organ transplant, iatrogenic (chemotherapy and steroids)Most common fungiAspergillus(a. fumigatus,a.flavus)MucormycosisMucor, Rhizopus, AbsidiaLess common fungiCandidaBipolarisFusarium

25-07-2012www.nayyarENT.com22Acute Fulminant Invasive Fungal SinusitisPathogenesisSpores inhaled fungus grows in warm, humid sinonasal cavityFungi invade neural and vascular structures with thrombosis of feeding vesselsMucor causes obliterative vascular invasion leading to ischemia.Necrosis and loss of sensation acidic environment further fungal growthPt receiving renal dialysis and deferoxamine are at higher risk for mucormycosis.Extrasinus extension occurs via bony destruction, perineural and perivascular invasionNasal and palate mucosa destroyedFacial anesthesiaProptosisCranial nerve deficitsMental status changes

25-07-2012www.nayyarENT.com23Acute Fulminant Invasive Fungal SinusitisOther signs/symptomsFever (most common 90% of cases)Loss of sensation over face or oral cavityUlceration of face and sinonasal/palatal mucosaRhinorrhea, facial pain/anesthesia, headachesSeizures, CN deficitsFast progressing symptomsIn some cases, hours to days till death!

25-07-2012www.nayyarENT.com24Acute Fulminant Invasive Fungal SinusitisEndoscopic findingsLoss of sensation and change in appearance of mucosa (pale or black)Most consistent findingUlcerations and black mucosa are late findings(mucormycosis)Serial examinations are required

25-07-2012www.nayyarENT.com25Acute Fulminant Invasive Fungal SinusitisBiopsy + CultureShould always be performed when:Suspect fungal diseaseChange in sensation or color of mucosaAny immunocompromised patient with signs of sinusitis who fails to improve after 72 hours of IV antibiotics

Where?Diseased mucosa (pale, insensate, ulcerative, black)Normal appearance/sensationMiddle turbinate most common spot for AFIFS (67%)Septum 24% of cases

Must request silver staining

CultureVery difficult to get (+) result, especially with Mucormycosis

25-07-2012www.nayyarENT.com26Acute Fulminant Invasive Fungal SinusitisRadiographic studiesCT sinusMRI to assess tissue invasion, and orbital, intracranial, or neural involvementFindingsCTBone erosion and extrasinus extension classic findingSevere, unilateral mucosal thickeningThickening of periantral fat planes25-07-2012www.nayyarENT.com27Acute Fulminant Invasive Fungal SinusitisMRIObliteration of the periantral fatLeptomeningeal enhancement (intracranial extension)Granuloma formationHypointense on T1 and T2Extrasinus extensionCavernous sinus involvementAbsent flow void of carotidSoft tissue thickening of the involved sinus25-07-2012www.nayyarENT.com28Acute Fulminant Invasive Fungal SinusitisCombination of medical and surgical treatmentMedicalCorrect the underlying compromised stateReverse DKA and improve hydration80% survival if done promptlyAbsolute neutrophil count< 1000 = poor prognosisWBC transfusion and granulocyte colony stimulating factor to increase ANC25-07-2012www.nayyarENT.com29Acute Fulminant Invasive Fungal SinusitisMedical treatmentSystemic antifungalsAmphotericin B infusion1mg/kg/daySerious side effectsototoxicity, nephrotoxicity (occurs in 80% of cases)

Lipid-based form of Amphotericin BMore expensiveLess toxicCan achieve higher concentrations of drug5mg/kg/day

Posaconazole effect on mucor and aspergillus,may become antifungal of choice for mucormycosis in future.it is an option for step-down therapy from iv amphotericin B.

voriconazoleUsed most often when Aspergillus involvedMuch less toxic than Amphotericin BMucormycosis are resistant to these.

25-07-2012www.nayyarENT.com30Acute Fulminant Invasive Fungal SinusitisTopical Amphotericin B rinsesHave shown some success, but mixed resultsSurgical treatmentGoalsDecrease pathogen loadRemove devitalized tissueEstablish pathways for sinus drainage

Debride until clear, bleeding margins25-07-2012www.nayyarENT.com31Acute Fulminant Invasive Fungal SinusitisEndoscopic vs. Open proceduresRecommend endoscopic in early course of diseaseDecreased morbiditySimilar survival rates as open proceduresAdvanced disease (orbit, palatal, skin)Open approach requiredOnce disease has gone intracranial, prognosis is very poor.25-07-2012www.nayyarENT.com32Acute Fulminant Invasive Fungal SinusitisPrognosisMortality rate: 18-80%Early detection and treatment = much better chance of survivalIntracranial involvementMost predictive indicator for mortality70%+ mortality rateAbsolute Neutrophil Count (ANC) < 1000Worse prognosisRecovery from neutropenia = most predictive indicator for survivalMucormycosis = more fatalDiabetics tend to do worseGreater incidence of Mucormycosis in these patients25-07-2012www.nayyarENT.com33Chronic Invasive Fungal SinusitisSlower disease process than acuteRareBiggest difference:Most patients are immunocompetentCommon fungiAspergillus (most common - >80% of cases)BipolarisCandidaMucormycosis25-07-2012www.nayyarENT.com34Chronic Invasive Fungal SinusitisSigns/SymptomsSimilar to symptoms of chronic rhinosinusitisNasal congestion, rhinorrhea, facial pressure, headaches, polyposisProptosis, visual changes, anesthesia of skin, epistaxisMore concerningDoes not respond to antibioticsWorsens with steroids

25-07-2012www.nayyarENT.com35Chronic Invasive Fungal SinusitisDiagnosisFull H&N examination with nasal endoscopyNasal polyps, thick mucusRarely find ulcerationsBiopsy if suspect fungal disease or note any changes

CT & MRISimilar findings to AFIFS bony destruction, extrasinus extension, unilateral25-07-2012www.nayyarENT.com36Chronic Invasive Fungal SinusitisDiagnosisPathologyInvasion of blood vessels, neural structures, and surrounding mucosaFew inflammatory cellsMajor difference between acute and chronic invasive diseaseNo Granuloma formationMain difference between chronic invasive fungal disease and granulomatous invasive fungal disease25-07-2012www.nayyarENT.com37Chronic Invasive Fungal SinusitisTreatmentSimilar to AFIFS surgical + medical

Surgeryresect all involved tissue to expose bleeding margins

Systemic antifungalsStart with Amphotericin B until can rule out MucormycosisBest length of treatment not well studied Most recommend 3-6 months of therapy

Topical Amphotericin B sinus rinses

Close F/U and debridement requiredBiopsy anything that is suspicious as asymptomatic recurrence is not uncommon25-07-2012www.nayyarENT.com38Granulomatous Invasive Fungal SinusitisAppears exactly like CIFSVery rarePresence of multinucleated giant cell granulomasMost important difference between Chronic and Granulomatous diseaseAspergillus flavusMost often seen in North Africa and Southeast Asia25-07-2012www.nayyarENT.com39Granulomatous Invasive Fungal SinusitisPresentation and work-up are exactly the same as CIFSTreatmentSurgical resection to bleeding marginsTopical antifungal rinsesSystemic antifungalsOral voriconazole or itraconazoleMinority of authors believe systemic antifungals not requiredClose F/U and debridement requiredBiopsy anything that is suspicious as asymptomatic recurrence is not uncommon25-07-2012www.nayyarENT.com40 thank you

For more .ppts , visit www.nayyarENT.com

25-07-2012www.nayyarENT.com41