A prospective study of clinical profile of chronic rhinosinusitis in a tertiary care centre.
Definition and Classifications
The term rhinosinusitis refers to a group of disorders characterised by inflammation of mucosa of the nose and paranasal sinuses. As the nose is invariably involved with paranasal sinuses and the mucosa of nose and paranasal sinuses lays in continuity the term rhinosinusitis is a more preferred term. (1) This disease has got diverse symptomatology and has got a negative impact on quality of life. To tackle the difficult issues related to defining, staging and research of rhinosinusitis, the American Academy of Otolaryngology Head and Neck Surgery convened a multidisciplinary in August 1996. (2) As a result of it the article "Adult Rhinosinusitis Defined" has emerged in 1997 and was endorsed by the American Academy of Otolaryngologic Allergy and American Rhinologic Society (AAO-HNS) and later was modified by contributions of Lanza and Kennedy. (3) Acute rhinosinusitis is typically subdivided into Acute Bacterial Rhinosinusitis (ABRS) or Acute Viral Rhinosinusitis (AVRS). (4) Acute viral rhinosinusitis is usually self-limited, whereas bacterial rhinosinusitis presents with most of the symptoms they became the point of interest. (5) Rhinosinusitis can present in any age group without any gender predisposition. A study conducted by Wayne D Hsueh et al (6) on identifying clinical symptoms on improving the symptomatic diagnosis of CRS showed no significant differences between CRS and non-CRS patients in terms of age, sex and race. There is lack of evidence whether the male and female patients with rhinosinusitis were different and whether they should be treated differently. So a focused research in this area is warranted. (7) It affects between 5 to 15% of population according to Western literature. (8)
Fungal Hypothesis (9)
The fungal hypothesis proposes that patients with CRS mount an eosinophilic response to fungi with initial evidence showing some degree of fungi and eosinophilic mucin in all patients with CRS. The intranasal fungi in a patient with CRS would probably exacerbate the disease process through protease effects on nasal epithelial cells as well as activated eosinophils and lymphocytes present in the nose.
MATERIALS AND METHODS
This is a Prospective study conducted between April 2014 and March 2015 in the ENT OPD of Government Medical College, Thiruvananthapuram; 314 patients with chronic rhinosinusitis attending the Outpatient Department of ENT, Government Medical College, Thiruvananthapuram were included. All patients attending the Outpatient Department were studied.
1. Chronic rhinosinusitis patients fulfilling the diagnostic criteria.
2. Patients in the age group of 18-70 years.
3. Both males and females.
1. Patients less than 18 years and more than 70 years.
2. Those not willing to participate in the study.
3. Patients who underwent previous nasal surgery.
Semi-structured questionnaire regarding detailed history, duration and severity of symptoms are collected from the patients who attended the Outpatient Department of Otorhinolaryngology. Patients were examined in detail which included anterior rhinoscopy and diagnostic nasal endoscopy. Patients were given medical management with antibiotics, topical steroids, decongestants and nasal douche for 3 weeks and kept under followup. Patients were continued on topical steroids for 3 months, following which patients were re-examined. Computed tomography of nose and paranasal sinuses (Axial, coronal and sagittal view) was taken for patients without symptomatic improvement. They were taken up for Functional Endoscopic Sinus Surgery. Per-operative findings were recorded. Allergic mucin noted during surgery was sent for microbiology, fungal culture and sensitivity and fungal strain identified and recorded. A semi-structured questionnaire was used to elicit demographic data, anterior rhinoscopy and diagnostic nasal endoscopy. Wherever necessary computed tomography of nose and paranasal sinuses was done. Functional Endoscopic Sinus Surgery was done in patients with correct indications. Swabs and materials from the surgical site were sent to Microbiology Department for fungal strain identification and culture.
Qualitative data is expressed in percentage and proportion. Quantitative data is expressed in mean and standard deviation. Association is measured by Chi square test. Data entered in Microsoft Excel and analysed using SPSS.
OBSERVATIONS AND RESULTS
Among the total number of 314 patients' data collected 164 were females (52%) and 150 were males (48%) (Table 1).
Among 314 patients in the study, the most common age group was 31-40 years (23%)). Others were 41-50 years (22%), 21-30 years (19%), 51-60 years (17%), 10-20 years (11%) and 61-70 years (8% >). Mean age group of sample was found to be 40 years with standard deviation of 14.2 (Table 2),
Among the 314 patients observed, the average period for which the patients suffered from chronic rhinosinusitis was 3.7 years. Duration varied from 4 months to 40 years (Table 3),
Among the 314 patients, majority of patients (79% >) had symptoms for 1-5 years. Among the 314 patients, it was found that the most common symptom was headache (84% >) followed by nasal discharge (59%), nasal block (58% >) and facial congestion (57% >). Other results and analysis symptoms were facial pain, halitosis, anosmia/hyposmia, fatigue, fever, epistaxis, cough and dental pain (Table 4).
Among 314 patients 58% had nasal block, of which 42% had bilateral nasal block and 16% had unilateral nasal block (Table 5).
Among 314 patients 42% did not have nasal block, 49% had progressive nasal block and 9% had non-progressive nasal block (Table 6).
Among the patients with nasal block (183 patients), 84% patients had progressive nasal block and 16% patients had non-progressive nasal block (Table 7).
Among 314 patients in the study 42% patients did not have nasal block, 5% had mild nasal block, 41% had moderate nasal block and 12% had severe nasal block (Table 8).
Among 314 patients, 45% patients had facial pain and 55% did not have facial pain (Table 9).
Among 314 patients in the sample 55% patients did not have facial pain, 8% patients had mild facial pain, 35% had moderate facial pain and 2% of patients had severe facial pain (Table 10).
Among 314 patients, 57% patients had facial congestion and 43% of patients did not have facial congestion (Table 11).
Among 314 patients in the study, 10% of patients had mild facial congestion, 44% had moderate facial congestion, 3% of patients had severe facial congestion and 43% patients did not have facial congestion (Table 12).
Among 314 patients in the study, 59% of patients had nasal discharge as one of the presenting symptom and 41% did not have nasal discharge (Table 13).
While analysing 314 patients in the study, 71% of patients did not have any olfactory disturbance and 29% of patients were having olfactory disturbance, of which 4% of patients were having Anosmia and 25% of patients were having Hyposmia (Table 14).
Among 314 patients in the study, 16% did not have headache, 3% had mild headache and 23% had moderate headache and severe headache in 58% of patients (Table 15).
Among 314 patients in the study, 42% of patients had halitosis and 58% of patients did not have Halitosis (Table 16).
Among 314 patients in the study, 96% patients did not have dental pain, 2% had mild dental pain and 2% had moderate dental pain (Table 17).
Among 314 patients in the study, 11% of patients had cough and 89% of patients did not have Cough (Table 18).
Among 314 patients, 21% of patients had fatigue and 79% of patients did not have fatigue (Table 19).
Among 314 patients, 21% of patients had fever and 79% of patients did not have fever (Table 20).
While analysing 314 patients, it was found that 14% of patients had Epistaxis as one of the presenting symptom and 86% did not have Epistaxis (Table 21).
Among 314 patients in the study, 5% of patients had asthma and 95% of patients did not have Asthma (Table 22).
Among 314 patients, 64% > of patients gave history of allergy and 36% of patients did not have allergy (Table 23).
Distribution of sample according to position of septum. While analysing the septum of 314 patients, it was found that 81% of patients had a deviated nasal septum and in 19% patient's septum was central (Table 24).
While analysing 314 patients, it was found that 83% of patients had mucosal congestion on examination and 17% of patients did not have mucosal congestion (Table 25).
While analysing 314 patients 68% of patients had nasal discharge on examination, of which 50% had mucoid discharge and 19% had purulent discharge; 31% of patients did not have any nasal discharge (Table 26).
Distribution of sample according to polyp. While analysing 314 patients in the study 31% of patients had nasal polyp on examination, of which 9% had unilateral nasal polyp and 22% had bilateral nasal polyp; 69% of patients did not have any nasal polyp (Table 27).
Distribution of sample according to posterior rhinoscopy findings.
During posterior rhinoscopy examination of 314 patients, 47% patients were normal and 34% patients had discharge, 13% polyp and 6% with both polyp and discharge (Table 28). While analysing the endoscopic score of 314 patients, the average score was 5.59 which varied from 0-12. While analysing the CT score of 254 patients, the average score was 11.04, which varied from 2 to 22. CT was taken only in patients whose symptoms persisted even after 3 months of medical treatment (Table 28),
Distribution of sample according to mode of treatment. Among 314 patients included in the study, 20% of patients were managed medically and rest 80% were managed with combined medical and surgical management (Table 29).
Among 254 patients who underwent surgery, 46%) of patients had oedematous mucosa, 33.4%) of patients had polyp, 1.6% patients had fungal debris alone, 4.3% of patients had oedematous mucosa and pus, 2.8% of patients had oedematous mucosa and polyp, 5.1% of patients had oedematous mucosa and fungal debris, 3.1% of patients had oedematous mucosa, fungal debris and pus, 0.3% of patients had polyp and fungal debris, 2.8% of patients had oedematous mucosa, polyp and fungal debris, polyp and pus was present in 0.3%) of patients and 0.3% of patients had oedematous mucosa, polyp, fungal debris and pus. Among 254 patients who underwent surgery, 34 patients had fungal debris (10.8% among total CRS patients) (Table 30).
Among 34 patient's sample sent for fungal culture and sensitivity, 94%) of fungal species isolated were Aspergillus, 3% Mucorand 3% Candida (Table 31).
This study included 314 consecutively selected patients with chronic rhinosinusitis, who presented to the Outpatient Department of Otorhinolaryngology, Medical College, Thiruvananthapuram during the study period of 1 year from April 2014 to April 2015. In the present study, a humble attempt was made to identify the clinical profile of patients with chronic rhinosinusitis. Patients who were taken up for surgery were followed up to operation table to find out the intraoperative findings and the patients with fungal sinusitis were noted and an attempt was also made to identify the species of fungus from microbiology. The results obtained were compared with many studies conducted previously. In the study, chronic rhinosinusitis was having an approximately equal distribution among males and females; Males 48%) and Females 52% with a ratio of 1.08:1. Quing Ling Fu et al (9) had 51.2%) females in their study. Engin Dursun et al (10) had a similar ratio of 1.1:1, Tomasz Grzegorzek et al (11) had a ratio of 1:1, Seyyed Abdollan Madani et al (12) and Ayman Al Madani et al (13) had males more than females in their study. Francis T K et al (14) male-to-female ratio of 1.1:1. The mean age group of presentation was 40 years in the study with a standard deviation of 14.2, which coincides with studies of Ayman Al Madani et al (13) where most common age group was 40 years. S P Gulati et al (15) had it as 30-37 years of age. Tomasz Grzegorzek et al (11) had a mean age group of 46.5 years, Bhattacharyya et al (16) had a mean age group of 42.3 years and James N Baraniuk et al (17) had a mean age group of 45.1 years. In our study, the average duration of symptoms was 3.7 years. Majority of patients had a duration of 1-5 years. Arild Danielsen et al (18) had mean symptom period as 2 to 12 years. In this study the common presenting symptoms were headache, nasal block and facial congestion, which coincided with studies of Bhattacharyya et al (16); 58% patients presented with nasal block in our study, among which 42% had bilateral and 16% had unilateral nasal block. Andre Alencar et al (19) had 83.7% of patients with nasal block. Bhattacharya N et al (16) had 51.8%) patients with nasal block. Mohammed Naieni et al (20) had 79.31% and T Shivakumar et al (21) had 86.66% patients with nasal block. Y Bajaj et al (22) and S P Gulati et al (15) showed the most common symptom as nasal block. Francis T K et al (14) had 84% patients with nasal obstruction. In this study, 45%) patients presented with facial pain which coincided with Bhattacharya N et al (23) with 47.3%) patients with facial pain. Andre Alencar et alt (19) had a variable presentation of facial pain in up to 80% of patients. D Hastan et al (24) had 64.7% patients with facial pain. T Shivakumar et al (21) had 73.3%) patients with facial pain; 57%) patients presented with facial congestion in our study. Bhattacharya N et al (23) had approximately 47%) patients with facial congestion. Francis T K et al (14) had 79%) patients with facial congestion. In this study, 59% of patients had history of nasal discharge which coincides with the study of T Shivakumar et al (21) where 58.09%) patients had nasal discharge. Mohammed Naiemi et al (20) had 75.64%) patients with nasal discharge. Tomasz Grzegorzek et al (11) had 67.92%) patients with nasal discharge. Wilma T Anselmo et al (25) had 63.6%) patients with nasal discharge. Olfactory disturbance was present in 29%) patients in our study, of which 14%) (13 patients) had anosmia and 86%) (78 patients) had hyposmia. Wilma T Anselmo et al (25) had 46% patients with olfactory disturbance. Mohammad Naiemi et al (19) had 87.18%) patients with olfactory disturbance. T Shivakumar et al (21) had 77.14%) patients with olfactory disturbance. In our study, 84%) patients presented with headache. Tomasz Grzegorzek et al (11) had 56.6%) patients with headache. H Gheriani eta (26) had 43.5% patients who had headache. T Shivakumar et al (21) had 62.83%) patients with headache and Mohammed Naeimi etaK20) had 38.46%) patients with headache. In this study, 42% patients presented with history of halitosis. Mohammad Naeimi et al (20) had 50% patients with halitosis. T Shivakumar et al (21) had 26.6% with halitosis, 5% patients had history of dental pain in our study. T Shivakumar et al (21) had 10.4% > patients with dental pain and Mohammad Naiemi et al (20) had 70% of patients with dental pain. It was observed that 11% of patients had history of cough in our study, which coincides with the study of T Shivakumar et al, (21) where 11.42% patients had history of cough. Mohammad Naeimi et al (20) observed 45% patients with cough. A H Morice committee members (27) had 4% patients with cough; 21% patients had fatigue in our study. James N Baraniuk et al (28) had 26% patients with fatigue. T Shivakumar et al (21) had 30.47%) patients with fatigue. In our study, 21% patients had history of fever (during acute exacerbations). Mohammad Naeimi et al (20) had 55% patients with fever; 14% of patients had history of epistaxis during the course of disease in our study. Isek K R et al (29) had 22% patients with epistaxis. In this study, 5% patients had history of asthma. Wilma T Anselmo et al (25) had 7% patients with asthma. Ahammed R Sedaghat et al (30) observed 19% patients with history of asthma. Tomasz Grzegorzek et al (11) had 26.8% > with asthma. L Badia et al (31) had 50% patients with coexistent asthma. D Jarvis et al (32) had a strong association between asthma and chronic rhinosinusitis. Jens U et al observed (33) 71% patients with history of asthma. In our study, 64% patients gave history of allergy. Engin Dursun et al (10) observed coexistence of allergy in 36.2% of patients. Isek KR et al (29) observed 28.8% of patients with associated allergy. Ahmad R Sedaghat et alt (30) observed an association of 27.5% patients with allergy; 81% patients had deviated nasal septum on examination in this study, which was similar to the study conducted by Seyyed Madani et al, (12) in which nasal septal deviation was observed in 81.7% of patients. V K Poorey and Neha Gupta (34) observed a strong correlation between nasal septal deviation and sinus disease. Similarly Calhoun et al, RPS Harar and Zachary M Sole (35,36,37) also observed a strong association between sinonasal disease and deviated nasal septum. T Shivakumar et al (21) had 51.42%) patients with nasal septal deviation. In this study, mucosal congestion was observed in 83% patients. In this study, nasal discharge was observed in 69% of patients, of which 50% were mucoid and 19% were purulent which coincides with the study conducted by Tomasz Grzegorzek et al (10) in which nasal discharge was observed in 67.92%) of patients. T Shivakumar et al (21) observed mucopus in 19.07%) patients. In our study, nasal polyposis was observed in 31% of patients, of which 9% were unilateral and 22% were bilateral. Also in 19% of patients, polyp was visible on posterior rhinoscopic examination. This coincided with the observation made by Tomasz Grzegorzek et al, (10) in which nasal polyp was found in 31.13%) of patients. James N Baranuik et al (17) observed nasal polyposis in 50% of patients. Observation made by W J Videler et al (31) showed presence of nasal polyposis in 52% of patients and 44.7% of patients in the study by T Shivakumar et al. (21) Postnasal discharge was observed in 40% of patients in our study. Study conducted by A H Morice (27) committee members observed post-nasal discharge in 60% of patients. T Shivakumar et al (21) observed post-nasal discharge in 70.47%) patients. In this study, the mean endoscopic score of the patients was 5.59. In the observation made by Kristen A Smith et al, (38) the mean endoscopic score was 6.3 in Asians. Observation made by Kristen A Smith et al (38) in a study was 6.9. In the present study, the mean CT score by Lund McKay score was 11.04. The observations made in mean CT score in study by Mikah M Likness et al (39) was 14.33, Kristen A Smith et al (38) was 13.5, Zachaiy M Sole et al (37) was 14.6 and W J Videler et al (31) was 13.5. Continued medical management were given for 20% patients and medical management followed by surgical management were given for 80% patients in our study, which almost coincides with the study of Enema Job Amodu et al (40) in which continued medical management was given for 20.7% > patients and combined medical and surgical management for 79.2% patients. In a study conducted by Kristen A Smith et al, (38) they came to the conclusion that continued medical therapy provides no additional benefits while Endoscopic Sinus Surgery provides significant improvement in several important clinical outcomes. In the present study, a humble attempt was also made to identify the percentage of fungal sinusitis among chronic rhinosinusitis and also to identify the species of fungi causing sinusitis. In this study, 10.8% > of patients had fungal sinusitis. Engin Dursun and Hakan Korkmaz et al (10) observed 13%, Seyyed Abdollah Madani et al (12) observed 12.1% and Ayman Al Madani et al (13) observed 16% prevalence of fungal sinusitis in their study. Study conducted by Arunaloke Chakrabarti et al (41) observed a very high prevalence of 27.5% in the study. In the present study, 94% of fungi were Aspergillus species, 3% candida and 3% mucor. In a study conducted by Arunaloke Chakrabarti et al, (41) 97.6% of fungi were Aspergillus species.
The mean age group of patients with chronic rhinosinusitis was 40 years. Chronic rhinosinusitis have almost equal distribution among males and females. Common presenting symptoms were headache, nasal discharge and nasal obstruction. Anatomical variations like deviated nasal septum can predispose to chronic rhinosinusitis. Chronic rhinosinusitis is more common in patients with allergic rhinitis. Mucosal congestion, oedematous mucosa and polyp were the common findings during examination. Most common fungal species isolated in culture was Aspergillus. Surgery plays a significant role in the management of refractory cases of chronic rhinosinusitis.
The sample size was very small compared to the global burden of chronic rhinosinusitis. The time period of study was limited. Being a tertiary care centre, we had a refractory group of patients. So a good number of patients needed surgical management. Allergic rhinitis was diagnosed by history, confirmatory tests were not performed. Long term followup is needed to assess the surgical results.
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Sindhu V. Nath , Susan James , Nimisha Suresh 
 Associate Professor, Department of ENT, Government Medical College, Thiwvananthapuram, Kerala.
 Associate Professor, Department of ENT, Government Medical College, Thiwvananthapuram, Kerala.
 Postgraduate Student, Department of ENT, Government Medical College, Thiwvananthapuram, Kerala.
Financial or Other, Competing Interest: None.
Submission 16-01-2017, Peer Review 08-02-2017,
Acceptance 15-02-2017, Published 23-02-2017.
Dr. Sindhu V. Nath, Associate Professor, Department of ENT, Governmen t Medical College, Thiruvanan thapuram, Kerala.
Table 1. Percentage Distribution of Sample according to Sex Sex No. of Patients Percentage Female 164 52% Male 150 48% Total 314 Table 2. Age Wise Distribution Age in Years Male Female Total No. % of Patients 10-20 Years 21 12 33 11% 21-30 Years 27 33 60 19% 31-40 Years 29 44 73 23% 41-50 years 35 35 70 22% 51-60 Years 24 29 53 17% 61-70 Years 14 11 25 8% Mean [+ or -] SD39.9 [+ or -] 14.2 Table 3. Duration of Symptoms Duration of No. of Percentage Symptoms in Years Patients 1-5 Years 249 79.3% 6-10 Years 49 15.6% 11-15 Years 8 2.5% 16-20 Years 5 1.6% 21-25 Years 0 0.0% 26-30 Years 1 0.3% 31-35 Years 0 0.0% 36-40 Years 2 0.6% Total 314 Table 4. Presenting Symptoms Presenting Symptoms Present Percentage (%) Nasal Block 183 58% Facial Pain 141 45% Facial Congestion 179 57% Headache 265 84% Dental Pain 17 5% Nasal Discharge 186 59% Epistaxis 45 14% Anosmia/Hyposmia 91 29% Halitosis 133 42% Fever 52 17% Fatigue 66 21% Cough 36 11% Table 5. Nasal Block Category No. of Patients Percentage No block 131 42% Unilateral 50 16% Bilateral 133 42% Total 314 100% Table 6. Nasal Block Nature Nature No. of Patients Percentage No block 131 42% Non-Progressive 29 9% Progressive 154 49% Total 314 Table 7. Nasal Block Nature Nature No. of Patients Percentage Non-Progressive 29 16% Progressive 154 84% Total 183 100% Table 8. Nasal Block Severity Nasal Block Severity No. of Patients Percentage No Nasal Block 132 42% Mild Nasal Block 15 5% Moderate Nasal Block 128 41% Severe Nasal Block 39 12% Total 314 100% Table 9. Facial Pain Facial Pain No. of Patients Percentage No Facial Pain 173 55% Facial Pain 141 45% Total 314 100% Table 10. Facial Pain Severity Facial Pain No. of Patients Percentage No Facial Pain 173 55% Mild Facial Pain 25 8% Moderate Facial Pain 111 35% Severe Facial Pain 5 2% Total 314 100% Table 11. Facial Congestion Facial Congestion No. of Patients Percentage No Facial Congestion 135 43% Facial Congestion 179 57% Total 314 Table 12. Facial Congestion Severity Facial Congestion No. of Patients Percentage No Facial Congestion 135 43% Mild Facial Congestion 31 10% Moderate Facial Congestion 137 44% Severe Facial Congestion 11 3% Total 314 Table 13. Nasal Discharge Nasal Discharge No. of Patients Percentage Present 186 59% Absent 128 41% Total 314 100% Table 14. Olfactory Disturbance Hyposmia Anosmia Absence of Olfactory Disturbance 78 13 223 25% 4% 71% Table 15. Headache Headache No. of Patients Percentage No Headache 49 16% Mild Headache 11 3% Moderate Headache 71 23% Severe Headache 183 58% Total 314 100% Table 16. Halitosis Halitosis No. of Patients Percentage Present 133 42% Absent 181 58% Total 314 Table 17. Dental Pain Dental Pain No. of Patients Percentage No Dental Pain 303 96% Mild Dental Pain 5 2% Moderate Dental Pain 6 2% Severe Dental Pain 0 0% Total 314 100% Table 18. Cough Cough No. of Patients Percentage Present 36 11% Absent 278 89% Total 314 100% Table 19. Fatigue Fatigue No. of Patients Percentage Present 66 21% Absent 248 79% Total 314 Table 20. Fever Fever No. of Patients Percentage Present 66 21% Absent 248 79% Total 314 100% Table 21. Epistaxis Epistaxis No. of Patients Percentage Present 45 14% Absent 269 86% Total 314 100% Table 22. Asthma Asthma No. of Patients Percentage Present 16 5% Absent 298 95% Total 314 100% Table 23. Allergy Allergy No. of Patients Percentage Present 201 64% Absent 113 36% Total 314 Table 24. Examination Findings of Septum Septum Patients Percentage Deviated 253 81% Not Deviated 61 19% Total 314 100% Table 25. Mucosal Congestion Mucosal Congestion Patients Percentage Present 262 83% Absent 52 17% Total 314 100% Table 26. Other Examination Findings of Nasal Discharge Nasal Discharge 98 158 58 31% 50% 19% Examination Findings of Septum Table 27. Polyp Absent Unilateral Bilateral 216 30 68 69% 9% 22% Table 28. Posterior Rhinoscopy Posterior Rhinoscopy No. of Patients Percentage Normal 146 47% Discharge 106 34% Polyp 42 13% Discharge and Polyp 20 6% Table 29. Management Management Patients Percentage Medical Management 60 20% Medical + Surgical Management 254 80% Total 314 100% Table 30. Surgical Findings Findings No. of Patients % Oedematous mucosa 116 46% Polyp 85 33.4% Fungal debris 4 1.6% Oedematous mucosa + Pus 11 4.3% Oedematous mucosa + Polyp 7 2.8% Oedematous mucosa + Fungal debris 13 5.1% Oedematous mucosa + Fungal 8 3.1% debris + Pus Polyp + Fungal debris 1 0.3% Oedematous mucosa + Polyp + 7 2.8% Fungal debris Polyp + Pus 1 0.3% Oedematous mucosa + Polyp + Fungal 1 0.3% Debris + Pus table 31. Fungal Strain Microbiology--Fungal Strain Aspergil Muc Candi Curvula Bipola lus or da ria ris 32 1 1 0 0 94% 3% 3% 0% 0%
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|Title Annotation:||Original Research Article|
|Author:||Nath, Sindhu V.; James, Susan; Suresh, Nimisha|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Feb 23, 2017|
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