- Email: [email protected]
Aspergillus Infection of Paranasal Sinuses
CLINICAL STUDY
Aspergillus Infection of Paranasal Sinuses Maroof Aziz Khan FCPS, Abid Rasheed FCPS, Muhammad Rashid Awan DLO, Azhar Hameed FCPS Department of Ear, Nose, Throat and Head and Neck Surgery-Unit 1, Mayo Hospital King Edward Medical University, Lahore, Pakistan
Abstract
Objectives Aspergillus sinusitis is not an uncommon disease in our part of the world. There is still no consensus on classification of the disease and treatment methods have also not been standardized as yet. We assessed clinical characterization of the pattern of the disease in this clinical study. Methods A total of 23 consecutive patients undergoing external ethmoidectomy for suspected fungal sinusitis were selected for the study. All patients included in the study were immunocompetent. Caseous material obtained following surgery was sent for microscopy with Potassium Hydroxide (KOH) and histopathological examination to know type of the fungus and nature of the disease. Results The average age of the patients was 27.7 years (SD 40±30). They ranged in age from 10 to 70 years. There were 17 (73.91 %) male and 6 (26.09 %) female patients in this study. M: F ratio was 1:0.35. In 19 (82.61 %) of 23 patients, Aspergillus species was found on microscopy and histopathological examination. Non-invasive disease revealed in 13 (56.52 %) and invasive in 6 (26.09) patients. In 4 (17.39 %) patients, simple inflammatory polyps were seen. Conclusion For all practical purposes, Aspergillus infection of paranasal sinuses can be broadly divided into two categories, non-invasive Aspergillus sinusitis that usually presents as fungus balls or caseous material without fungal tissue invasion and invasive Aspergillus sinusitis with presence of septate hyphae in the soft tissue. The final specimen obtained during surgery should be submitted for histopathological examination to detect invasion of the tissues as this has effects on further treatment of disease. Key Words: Aspergillus, External Ethmoidectomy, Paranasal Sinuses Journal of Taibah University Medical Sciences 2010; 5(2): 60 - 65
Correspondence to: Dr. Maroof Aziz Khan Associate Professor of ENT Unit 1, Mayo Hospital
King Edward Medical University, Lahore, Pakistan +92 3218436853 +92 4239923412 [email protected]
60
Maroof Aziz Khan et al
Introduction
Intracranial spread of the infection occurs due to close proximity of the sinuses with cranial cavity. It is a dreaded complication, as it is usually fatal if not treated promptly. Orbital involvement occurs by contiguous spread of the disease from paranasal sinuses, by expansion or bone erosion due to pressure effect of the polyps or fungal tissue invasion. It is considered to worsen the prognosis of sinonasal Aspergillosis. Moreover, the superior orbital fissure and optic canal directly open into the middle cranial fossa, and are ready pathways for further intracranial spread of the infection8.
S
ince first reported by Katzenstein and her colleagues in 1983, Aspergillus sinusitis is still poorly recognized regarding its classification, characterization and management. The combination of nasal polyps, crust formation and sinus cultures yielding the Aspergillus was first noted in 1976 by Safirstein1,2. Aspergillosis of Head and Neck region, primarily affects the nasal cavity and paranasal sinuses. Mucormycosis and Rhizopus stands far behind the Aspergillus in causing fungal sinusitis. There are more than 185 species of the Aspergillus and over 95 % of all infections are caused by Aspergillus Fumigatus, Aspergillus Flavus and Aspergillus Niger. Disease may present with nasal polyps, anterior and posterior nasal discharge, nasal obstruction, epistaxis, headache, anosmia, proptosis or snoring3. Aspergillus as a pathogen cannot actively penetrate undamaged and intact mucus membrane or skin as it lacks keratolytic enzymes. On the basis of this finding, paranasal sinus Aspergillosis is now classified into invasive (acute fulminant, chronic invasive, granulomatous invasive) and non-invasive (fungus ball and allergic fungal rhinosinusitis) forms with their own pathophysiology and clinical presentation. Any type of paranasal Aspergillosis may progress to more aggressive disease illustrating the importance of early recognition of this increasingly encountered disease4,5. Prerequisites for diagnosis are sinonasal polyps, infiltrative or non-infiltrative fungal hyphae on microscopy with Potassium Hydroxide (KOH) and histopathological examination of the resected polyps and positive fungal culture of the tissue following surgery. Successful treatment includes early diagnosis, pre and post operative steroids and antifungal therapy, surgical debridement of the polyps and caseous material with adequate drainage and ventilation along with control of the underlying disease6,7.
Materials and Methods This study was carried out in Department of Ear, Nose and Throat Unit 1, Mayo Hospital affiliated with King Edward Medical University, Lahore. It spanned over a period of 18 months from February 2007 to August 2008. A total of 23 consecutive patients undergoing external ethmoidectomy for suspected fungal sinusitis were selected for the study. All patients were evaluated with Computerized Tomography (CT) Scan after obtaining detailed history and performing clinical examination. Informed consent for the surgery was taken after being briefed about the procedure, its merits and demerits. External Ethmoidectomy with or without Cald Well Luc procedure was performed on all patients. The decision of external ethmoidectomy was based on the presence of proptosis, recurrent sinonasal polyposis, evidence of orbital invasion by sinonasal polyps on CT scan, presence of hyper dense masses in paranasal sinuses or bony erosion of the sinus walls with asymmetry of two sides. Resected polyps or cheesy material obtained following surgery was sent for microscopy with KOH and histopathological examination, to know the variety of the disease and the type of fungus. Demographic profile and relevant data was recorded in a standard Performa. Data was entered in Statistical Package for the Social Sciences (SPSS) version 11, a computer based soft ware. Mean and standard deviation were computed for
61 J T U Med Sc 2010; 5(2)
Aspergillus infection of paranasal sinuses
qualitative variables like age. Descriptive statistics like frequency and percentage were computed for categorical variables like gender, clinical and radiological features and type of the disease. Statistical test of significance was not applicable in this study.
Table 1: Analysis of common clinical features in patients (n=23) Clinical Features =n % age Proptosis 19 82.60 Nasal obstruction 18 78.26 Multiple nasal polyps 16 69.56 Sneezing& rhinorhhea 15 65.21 Headache 10 43.47 Epistaxis 5 21.73 Past history of TB 1 4.34
Results 23 consecutive patients undergoing external ethmoidectomy included in the study ranged in age from 10 to 70 years. The average age of the patients was 27.7 years (SD 40±30). M: F ratio was 1:0.35. There were 17 (73.91 %) male and 6 (26.09 %) female patients in this study. Proptosis, nasal obstruction and multiple nasal polyps were seen in 19 (82.60 %), 18 (78.26 %) and 16 (69.56 %) patients respectively, however sneezing or rhinorrhea, headache and epistaxis were found in 15 (65.21 %), 10 (43.47 %) and 5 (21.73 %) patients respectively. One (4.34 %) of 23 patients presented with past history of tuberculosis (Table 1). On CT scan (Figures 1 and 2), ethmoid sinus was involved in 19 (82.80 %) and sphenoid in 17 (73.91 %) patients. Similarly maxillary and frontal sinus involvement were seen in 16 (69.56 %) and 14 (60.86 %) patients respectively (Table 2). In 19 (82.61 %) of 23 patients, Aspergillus species were detected by microscopy of KOH preparation) and histopathological examination. Non-invasive disease revealed in 13 (56.52 %) and invasive in 6 (26.09) patients. In 4 (17.39 %) patients, simple inflammatory polyps were seen (Figure 3).
Table 2: Involvement of paranasal sinuses on CT scan (n=23) Sinus involved =n % age Ethmoid involvement 19 82.60 Sphenoid disease 17 73.91 Maxillary involvement 16 69.56 Frontal sinus disease 14 60.86
Figure 1: Double density sign (white arrows) of non-invasive aspergillus infection of paranasal sinuses on coronal contrast enhanced CT scan.
Discussion The role of fungi in nose and paranasal sinuses is unclear as when it present as a pathogen and when as a part of normal flora. Similarly classification, terminology, pathogenesis, and criteria for diagnosis are still the matters under debate and much remains to be learnt about its optimal management. Length and dosage of topical and oral steroids and antifungal drugs are also not clearly defined yet9-11.
Figure 2: Extensive sino-nasal polyposis (white arrow) involving all sinus cavities and nose on coronal contrast enhanced CT scan.
62 J T U Med Sc 2010; 5(2)
Maroof Aziz Khan et al
Non-invasive aspergillus
invasive aspergillus
They usually present with non-caseating granuloma and proptosis. They were distinguished from chronic invasive type, which has a chronic course and seen in subtly immunocompromised patients (with diabetes mellitus and on corticosteroid treatment with dense accumulation of hyphae invading tissue)15. Extensive polyps with intracranial or intraorbital extension are better dealt and exposed by transantral and external ethmoidectomy or craniofacial resection. However intranasal ethmoidectomy or functional endoscopic sinus surgery are better options for moderate disease. We used external ethmoidectomy approach in all patients due to extensive and recurrent disease in all patients16,17. The average age of the patients was 27.7 years (SD 40±30) and they ranged in age from 10 to 70 years. According to Akhtar et al, age distribution is somewhat variable however; most of the patients fell into 2nd 3rd and 4th decade of life18. As Aspergillus infection of paranasal sinuses is not a very common condition, there were 17 males and 6 females in this study. Comparing our results with local and international researchers’, Aspergillus is most commonly seen in young immunocompetent individuals with male predominance19,20. Sinuses involved on CT scan in order of frequency were ethmoid, sphenoid, maxillary and frontal sinuses respectively. Multiple nasal polyps seen in 16 (69.56 %) patients in this study, contrary to Thahim K et al where all (100 %) patients presented with multiple polyps. 19 (82.60 %) patients presented with proptosis. This high ratio of proptosis was contrary to a local study by Rehman et al, where it was in (8)33 % patients. Headache found in 10 (43.47 %) patients contrary to a local research where it was in 10 % of the patients16,21. Incidence of Aspergillus sinusitis is apparently more than what is reported in international literature and it principally represents as allergic fungal sinusitis as seen in this study. Aspergillus species was found in 19 (82.61 %) of 23 patients. Our result was in accordance with a local researcher Khan
inflammatory polyps
Figure 3: Incidence of non-invasive, invasive and inflammatory polyps. There is uncertainty about management of invasive sino-orbital Aspergillosis. Some authors recommend orbital exenteration to achieve the surgical margins while others note that vision sparing orbital debridement is adequate for the cure especially when supplemented by antifungal drug itraconazole12,13. An intact immune system can prevent the disease in a healthy individual and there may be mechanism by which fungi effect on the sinus mucosa in susceptible individuals only. In our study all the patients were immunocompetent. Noninvasive disease typically affects immunocompetent patients and it is usually not seen in patients with immune deficiency. Here adequate sinus surgery generally cures the disease. Invasive disease usually occurs in debilitated immunocompromised patients; however evidence in immunocompetent patients has been reported in the literature review. It requires prolonged medical treatment, as clearance by surgery is not usually possible because of lack of the line of demarcation between the disease and normal soft tissues, especially of the orbits14. In the late 1990s, deShazo et al proposed a new classification for tissue invasive fungal rhinosinusitis based on the clinical condition, immune status, histopathology, and fungus infection. These were acute (fulminant) invasive, granulomatous invasive and chronic invasive types. The chronic granulomatous invasive type was mainly noticed in immunocompetent patients from Sudan, India, and Pakistan.
63 J T U Med Sc 2010; 5(2)
Aspergillus infection of paranasal sinuses
et al where it was in 83.33 % of the patients. Contrary to this, it was in 60 % by Thahim et al and 70 % by Rehman et al. On the other hand, Aspergillus was present in only 10 % of the patients in a foreign study. It indicates decreased incidence of Aspergillus sinusitis in Europe compared to South Asia16,21-24. Non-invasive disease revealed in 13 (56.52 %) and invasive in 6 (26.09) patients. In 4 (17.39 %) patients, simple inflammatory polyps were seen. Our result differ with a local study in this regard, where noninvasive disease revealed in 24 %, invasive in 14 % and simple inflammatory polyps were found in 62 % of the patients16.
6.
7.
8.
9.
Conclusion For all practical purposes, Aspergillus infection of paranasal sinuses can be broadly divided into two categories, non-invasive Aspergillus sinusitis that usually presents as fungus balls or caseous material without fungal tissue invasion and invasive Aspergillus sinusitis with presence of septate hyphae in the soft tissue. The final specimen obtained during surgery should be submitted for histopathological examination to detect invasion of the tissues as this has effects on further management of disease.
10.
11.
12.
13.
References 1.
2.
3.
4.
5.
14.
Agarwal S, Kanga A, Sharma V, Sharma DR, Sharma M.L. Invasive aspergillosis involving multiple paranasal sinuses-a case report. Indian J Med Microbiol 2005; 23 (3): 195-197. Safirstein BH. Allergic bronchopulmonary aspergillosis with obstruction of the upper respiratory tract. Chest 1976; 70: 788-790. Barclay L, Lie D. Diagnosis of allergic fungal rhinosinusitis clarified. Arch Oto Laryngol Head Neck Surg 2006; 132: 173-178. Udaipurwala IH. Allergic fungal sinusitis: a perplexing clinical entity. Pak J Otolaryngol 2008; 24: 25-27. Jones JR. Paranasal aspergillosis-a spectrum of disease. J Laryngol Otol 1993; 108: 773-4.
15.
16.
17.
Joshul, Schlf, Ahmad MS. Chronic rhizopus invasive fungal rhinosinusitisin an immunocompetent host. Laryngoscope 2004; 114:15331550. Singh N, Bholodia NH. Allergic fungal sinusitis-earlier diagnosis and management. J Laryngol Otol 2005; 119; 875-881. Mauriello JA, Yepez N, Mostafavi R, Barofsky J, Kapila R, Baredes S et al. Invasive rhinosino-orbital aspergillosis with preeipituous visual loss. Opthalmol 2005;30: 124-130. Ferguson BJ. Definitions of fungal rhinosinusitis. Otolaryngol Clin North Am 2000; 33: 227-235. Saravan K, Panda NK, Chakarbarti A, Das A, Bapuraj RJ. Allergic fungal rhinosinusitis: an attempt to resolve the diagnostic dilemma. Arch Otolaryngol Head Neck Surg 2006; 132:173-178. Chakarbarti A, Das A, Panda NK. Controversies surrounding the categorization of fungal sinusitis. Med Mycol 2009; 47: 299-308. Adler SC, Isaacson G, Sasaki CT. Invasive aspergillosis. J Oto Laryngol 1997; 18: 230-234. Massry GG, Hornbiass A, Harrison W. Itraconazole in the treatment of orbital aspergillosis. Opthalmology 2000; 103: 1467-1470. Javaid M, Mehmudi S, Mohebbi S. Management of invasive fungal sinusitis. Pak J Otolaryngol 2008; 24:3839. Lackner A, Stammberger H, Buzina W, Freudenschuss K, Panzitt T, Schosteritsch et al. Fungi: a normal content of human nasal mucus. Am J Rhinol 2005; 19 (2): 125-129. Rehman Haq I, Qadri SH, Aqil S. Frequency of allergic fungal rhinosinusitis in patients with nasal polyps and associated risk factors. Pak J Med Health Sci 2009; 3:2-10. Ferguson BJ, Barnes L, Bernstein JM, Brown D, Clark CE, Cook PR et al. Geographic variations in allergic fungal rhinosinusitis. Otolaryngol Clin North Am 2000; 33:441-449.
64 J T U Med Sc 2010; 5(2)
Maroof Aziz Khan et al
18. Akhtar MR, Ishaque M, Saadat U. Etiology of nasal polyps. Pak J Otolaryngol 2004; 29:9-11. 19. Sinha V, Bhargwag D, Jeorge A, Memon RA. Proptosis through the eye of ENT surgeon. Indian J Otol Head Neck Surg 2005; 51 (3): 34-41. 20. Cody T 2nd, Neel HB 3rd, Ferreiro JA, Roberts GD. Allergic fungal sinusitis: the Mayo clinical experience. Laryngoscope 1994; 104:1074-1079. 21. Thahim K, Jawaid MA, Marfani MS. Presentation and management of
allergic fungal sinusitis. J Col Phys Surg Pak 2007; 17(1):23-27. 22. Jerome B. Paranasal sinus fungus. Am J Surg Path 2006; 30 (6): 713-720. 23. Khan AR, Ali F, Imran N, Khan NS, Din S. Invasive sino-orbital aspergillosis in immunocompetent host. J Med Sci 2009; 17 (2): 87-91. 24. Daghistani KJ, Jamel TS, Zaheer S, Naasif OI. Allergic Aspergillus sinusitis with proptosis. J Laryngol Otol 1992; 106:799-803.
65 J T U Med Sc 2010; 5(2)
Aspergillus Infection of Paranasal Sinuses Maroof Aziz Khan FCPS, Abid Rasheed FCPS, Muhammad Rashid Awan DLO, Azhar Hameed FCPS Department of Ear, Nose, Throat and Head and Neck Surgery-Unit 1, Mayo Hospital King Edward Medical University, Lahore, Pakistan
Abstract
Objectives Aspergillus sinusitis is not an uncommon disease in our part of the world. There is still no consensus on classification of the disease and treatment methods have also not been standardized as yet. We assessed clinical characterization of the pattern of the disease in this clinical study. Methods A total of 23 consecutive patients undergoing external ethmoidectomy for suspected fungal sinusitis were selected for the study. All patients included in the study were immunocompetent. Caseous material obtained following surgery was sent for microscopy with Potassium Hydroxide (KOH) and histopathological examination to know type of the fungus and nature of the disease. Results The average age of the patients was 27.7 years (SD 40±30). They ranged in age from 10 to 70 years. There were 17 (73.91 %) male and 6 (26.09 %) female patients in this study. M: F ratio was 1:0.35. In 19 (82.61 %) of 23 patients, Aspergillus species was found on microscopy and histopathological examination. Non-invasive disease revealed in 13 (56.52 %) and invasive in 6 (26.09) patients. In 4 (17.39 %) patients, simple inflammatory polyps were seen. Conclusion For all practical purposes, Aspergillus infection of paranasal sinuses can be broadly divided into two categories, non-invasive Aspergillus sinusitis that usually presents as fungus balls or caseous material without fungal tissue invasion and invasive Aspergillus sinusitis with presence of septate hyphae in the soft tissue. The final specimen obtained during surgery should be submitted for histopathological examination to detect invasion of the tissues as this has effects on further treatment of disease. Key Words: Aspergillus, External Ethmoidectomy, Paranasal Sinuses Journal of Taibah University Medical Sciences 2010; 5(2): 60 - 65
Correspondence to: Dr. Maroof Aziz Khan Associate Professor of ENT Unit 1, Mayo Hospital
King Edward Medical University, Lahore, Pakistan +92 3218436853 +92 4239923412 [email protected]
60
Maroof Aziz Khan et al
Introduction
Intracranial spread of the infection occurs due to close proximity of the sinuses with cranial cavity. It is a dreaded complication, as it is usually fatal if not treated promptly. Orbital involvement occurs by contiguous spread of the disease from paranasal sinuses, by expansion or bone erosion due to pressure effect of the polyps or fungal tissue invasion. It is considered to worsen the prognosis of sinonasal Aspergillosis. Moreover, the superior orbital fissure and optic canal directly open into the middle cranial fossa, and are ready pathways for further intracranial spread of the infection8.
S
ince first reported by Katzenstein and her colleagues in 1983, Aspergillus sinusitis is still poorly recognized regarding its classification, characterization and management. The combination of nasal polyps, crust formation and sinus cultures yielding the Aspergillus was first noted in 1976 by Safirstein1,2. Aspergillosis of Head and Neck region, primarily affects the nasal cavity and paranasal sinuses. Mucormycosis and Rhizopus stands far behind the Aspergillus in causing fungal sinusitis. There are more than 185 species of the Aspergillus and over 95 % of all infections are caused by Aspergillus Fumigatus, Aspergillus Flavus and Aspergillus Niger. Disease may present with nasal polyps, anterior and posterior nasal discharge, nasal obstruction, epistaxis, headache, anosmia, proptosis or snoring3. Aspergillus as a pathogen cannot actively penetrate undamaged and intact mucus membrane or skin as it lacks keratolytic enzymes. On the basis of this finding, paranasal sinus Aspergillosis is now classified into invasive (acute fulminant, chronic invasive, granulomatous invasive) and non-invasive (fungus ball and allergic fungal rhinosinusitis) forms with their own pathophysiology and clinical presentation. Any type of paranasal Aspergillosis may progress to more aggressive disease illustrating the importance of early recognition of this increasingly encountered disease4,5. Prerequisites for diagnosis are sinonasal polyps, infiltrative or non-infiltrative fungal hyphae on microscopy with Potassium Hydroxide (KOH) and histopathological examination of the resected polyps and positive fungal culture of the tissue following surgery. Successful treatment includes early diagnosis, pre and post operative steroids and antifungal therapy, surgical debridement of the polyps and caseous material with adequate drainage and ventilation along with control of the underlying disease6,7.
Materials and Methods This study was carried out in Department of Ear, Nose and Throat Unit 1, Mayo Hospital affiliated with King Edward Medical University, Lahore. It spanned over a period of 18 months from February 2007 to August 2008. A total of 23 consecutive patients undergoing external ethmoidectomy for suspected fungal sinusitis were selected for the study. All patients were evaluated with Computerized Tomography (CT) Scan after obtaining detailed history and performing clinical examination. Informed consent for the surgery was taken after being briefed about the procedure, its merits and demerits. External Ethmoidectomy with or without Cald Well Luc procedure was performed on all patients. The decision of external ethmoidectomy was based on the presence of proptosis, recurrent sinonasal polyposis, evidence of orbital invasion by sinonasal polyps on CT scan, presence of hyper dense masses in paranasal sinuses or bony erosion of the sinus walls with asymmetry of two sides. Resected polyps or cheesy material obtained following surgery was sent for microscopy with KOH and histopathological examination, to know the variety of the disease and the type of fungus. Demographic profile and relevant data was recorded in a standard Performa. Data was entered in Statistical Package for the Social Sciences (SPSS) version 11, a computer based soft ware. Mean and standard deviation were computed for
61 J T U Med Sc 2010; 5(2)
Aspergillus infection of paranasal sinuses
qualitative variables like age. Descriptive statistics like frequency and percentage were computed for categorical variables like gender, clinical and radiological features and type of the disease. Statistical test of significance was not applicable in this study.
Table 1: Analysis of common clinical features in patients (n=23) Clinical Features =n % age Proptosis 19 82.60 Nasal obstruction 18 78.26 Multiple nasal polyps 16 69.56 Sneezing& rhinorhhea 15 65.21 Headache 10 43.47 Epistaxis 5 21.73 Past history of TB 1 4.34
Results 23 consecutive patients undergoing external ethmoidectomy included in the study ranged in age from 10 to 70 years. The average age of the patients was 27.7 years (SD 40±30). M: F ratio was 1:0.35. There were 17 (73.91 %) male and 6 (26.09 %) female patients in this study. Proptosis, nasal obstruction and multiple nasal polyps were seen in 19 (82.60 %), 18 (78.26 %) and 16 (69.56 %) patients respectively, however sneezing or rhinorrhea, headache and epistaxis were found in 15 (65.21 %), 10 (43.47 %) and 5 (21.73 %) patients respectively. One (4.34 %) of 23 patients presented with past history of tuberculosis (Table 1). On CT scan (Figures 1 and 2), ethmoid sinus was involved in 19 (82.80 %) and sphenoid in 17 (73.91 %) patients. Similarly maxillary and frontal sinus involvement were seen in 16 (69.56 %) and 14 (60.86 %) patients respectively (Table 2). In 19 (82.61 %) of 23 patients, Aspergillus species were detected by microscopy of KOH preparation) and histopathological examination. Non-invasive disease revealed in 13 (56.52 %) and invasive in 6 (26.09) patients. In 4 (17.39 %) patients, simple inflammatory polyps were seen (Figure 3).
Table 2: Involvement of paranasal sinuses on CT scan (n=23) Sinus involved =n % age Ethmoid involvement 19 82.60 Sphenoid disease 17 73.91 Maxillary involvement 16 69.56 Frontal sinus disease 14 60.86
Figure 1: Double density sign (white arrows) of non-invasive aspergillus infection of paranasal sinuses on coronal contrast enhanced CT scan.
Discussion The role of fungi in nose and paranasal sinuses is unclear as when it present as a pathogen and when as a part of normal flora. Similarly classification, terminology, pathogenesis, and criteria for diagnosis are still the matters under debate and much remains to be learnt about its optimal management. Length and dosage of topical and oral steroids and antifungal drugs are also not clearly defined yet9-11.
Figure 2: Extensive sino-nasal polyposis (white arrow) involving all sinus cavities and nose on coronal contrast enhanced CT scan.
62 J T U Med Sc 2010; 5(2)
Maroof Aziz Khan et al
Non-invasive aspergillus
invasive aspergillus
They usually present with non-caseating granuloma and proptosis. They were distinguished from chronic invasive type, which has a chronic course and seen in subtly immunocompromised patients (with diabetes mellitus and on corticosteroid treatment with dense accumulation of hyphae invading tissue)15. Extensive polyps with intracranial or intraorbital extension are better dealt and exposed by transantral and external ethmoidectomy or craniofacial resection. However intranasal ethmoidectomy or functional endoscopic sinus surgery are better options for moderate disease. We used external ethmoidectomy approach in all patients due to extensive and recurrent disease in all patients16,17. The average age of the patients was 27.7 years (SD 40±30) and they ranged in age from 10 to 70 years. According to Akhtar et al, age distribution is somewhat variable however; most of the patients fell into 2nd 3rd and 4th decade of life18. As Aspergillus infection of paranasal sinuses is not a very common condition, there were 17 males and 6 females in this study. Comparing our results with local and international researchers’, Aspergillus is most commonly seen in young immunocompetent individuals with male predominance19,20. Sinuses involved on CT scan in order of frequency were ethmoid, sphenoid, maxillary and frontal sinuses respectively. Multiple nasal polyps seen in 16 (69.56 %) patients in this study, contrary to Thahim K et al where all (100 %) patients presented with multiple polyps. 19 (82.60 %) patients presented with proptosis. This high ratio of proptosis was contrary to a local study by Rehman et al, where it was in (8)33 % patients. Headache found in 10 (43.47 %) patients contrary to a local research where it was in 10 % of the patients16,21. Incidence of Aspergillus sinusitis is apparently more than what is reported in international literature and it principally represents as allergic fungal sinusitis as seen in this study. Aspergillus species was found in 19 (82.61 %) of 23 patients. Our result was in accordance with a local researcher Khan
inflammatory polyps
Figure 3: Incidence of non-invasive, invasive and inflammatory polyps. There is uncertainty about management of invasive sino-orbital Aspergillosis. Some authors recommend orbital exenteration to achieve the surgical margins while others note that vision sparing orbital debridement is adequate for the cure especially when supplemented by antifungal drug itraconazole12,13. An intact immune system can prevent the disease in a healthy individual and there may be mechanism by which fungi effect on the sinus mucosa in susceptible individuals only. In our study all the patients were immunocompetent. Noninvasive disease typically affects immunocompetent patients and it is usually not seen in patients with immune deficiency. Here adequate sinus surgery generally cures the disease. Invasive disease usually occurs in debilitated immunocompromised patients; however evidence in immunocompetent patients has been reported in the literature review. It requires prolonged medical treatment, as clearance by surgery is not usually possible because of lack of the line of demarcation between the disease and normal soft tissues, especially of the orbits14. In the late 1990s, deShazo et al proposed a new classification for tissue invasive fungal rhinosinusitis based on the clinical condition, immune status, histopathology, and fungus infection. These were acute (fulminant) invasive, granulomatous invasive and chronic invasive types. The chronic granulomatous invasive type was mainly noticed in immunocompetent patients from Sudan, India, and Pakistan.
63 J T U Med Sc 2010; 5(2)
Aspergillus infection of paranasal sinuses
et al where it was in 83.33 % of the patients. Contrary to this, it was in 60 % by Thahim et al and 70 % by Rehman et al. On the other hand, Aspergillus was present in only 10 % of the patients in a foreign study. It indicates decreased incidence of Aspergillus sinusitis in Europe compared to South Asia16,21-24. Non-invasive disease revealed in 13 (56.52 %) and invasive in 6 (26.09) patients. In 4 (17.39 %) patients, simple inflammatory polyps were seen. Our result differ with a local study in this regard, where noninvasive disease revealed in 24 %, invasive in 14 % and simple inflammatory polyps were found in 62 % of the patients16.
6.
7.
8.
9.
Conclusion For all practical purposes, Aspergillus infection of paranasal sinuses can be broadly divided into two categories, non-invasive Aspergillus sinusitis that usually presents as fungus balls or caseous material without fungal tissue invasion and invasive Aspergillus sinusitis with presence of septate hyphae in the soft tissue. The final specimen obtained during surgery should be submitted for histopathological examination to detect invasion of the tissues as this has effects on further management of disease.
10.
11.
12.
13.
References 1.
2.
3.
4.
5.
14.
Agarwal S, Kanga A, Sharma V, Sharma DR, Sharma M.L. Invasive aspergillosis involving multiple paranasal sinuses-a case report. Indian J Med Microbiol 2005; 23 (3): 195-197. Safirstein BH. Allergic bronchopulmonary aspergillosis with obstruction of the upper respiratory tract. Chest 1976; 70: 788-790. Barclay L, Lie D. Diagnosis of allergic fungal rhinosinusitis clarified. Arch Oto Laryngol Head Neck Surg 2006; 132: 173-178. Udaipurwala IH. Allergic fungal sinusitis: a perplexing clinical entity. Pak J Otolaryngol 2008; 24: 25-27. Jones JR. Paranasal aspergillosis-a spectrum of disease. J Laryngol Otol 1993; 108: 773-4.
15.
16.
17.
Joshul, Schlf, Ahmad MS. Chronic rhizopus invasive fungal rhinosinusitisin an immunocompetent host. Laryngoscope 2004; 114:15331550. Singh N, Bholodia NH. Allergic fungal sinusitis-earlier diagnosis and management. J Laryngol Otol 2005; 119; 875-881. Mauriello JA, Yepez N, Mostafavi R, Barofsky J, Kapila R, Baredes S et al. Invasive rhinosino-orbital aspergillosis with preeipituous visual loss. Opthalmol 2005;30: 124-130. Ferguson BJ. Definitions of fungal rhinosinusitis. Otolaryngol Clin North Am 2000; 33: 227-235. Saravan K, Panda NK, Chakarbarti A, Das A, Bapuraj RJ. Allergic fungal rhinosinusitis: an attempt to resolve the diagnostic dilemma. Arch Otolaryngol Head Neck Surg 2006; 132:173-178. Chakarbarti A, Das A, Panda NK. Controversies surrounding the categorization of fungal sinusitis. Med Mycol 2009; 47: 299-308. Adler SC, Isaacson G, Sasaki CT. Invasive aspergillosis. J Oto Laryngol 1997; 18: 230-234. Massry GG, Hornbiass A, Harrison W. Itraconazole in the treatment of orbital aspergillosis. Opthalmology 2000; 103: 1467-1470. Javaid M, Mehmudi S, Mohebbi S. Management of invasive fungal sinusitis. Pak J Otolaryngol 2008; 24:3839. Lackner A, Stammberger H, Buzina W, Freudenschuss K, Panzitt T, Schosteritsch et al. Fungi: a normal content of human nasal mucus. Am J Rhinol 2005; 19 (2): 125-129. Rehman Haq I, Qadri SH, Aqil S. Frequency of allergic fungal rhinosinusitis in patients with nasal polyps and associated risk factors. Pak J Med Health Sci 2009; 3:2-10. Ferguson BJ, Barnes L, Bernstein JM, Brown D, Clark CE, Cook PR et al. Geographic variations in allergic fungal rhinosinusitis. Otolaryngol Clin North Am 2000; 33:441-449.
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