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Endoscopic view of sphenoid fungal sinusitis.

A 63-year-old man presented with a 6-month history of right-sided headache and pain behind the right eye. He had been treated with several antibiotics by his family physician prior to referral.

Clinical evaluation revealed some mucopurulent discharge in the right superior nasal cavity and in the right nasopharynx (figure, A). Computed tomography (CT) of the sinuses revealed opacification of the right sphenoid sinus, but no evidence of bony erosion (figure, B). The patient elected to undergo right endoscopic sinus surgery for drainage purposes. Transnasal sphenoidotomy (1) was carried out with a microdebrider through the natural ostium of the right sphenoid sinus (figure, B). An inspissated fungus ball was found in the sphenoid sinus and removed (figure, C and D). The sphenoid sinus mucosa was not removed. Culture identified the fungus as a member of the Aspergillus genus. Postoperatively, the patient was treated with nasal saline irrigations and antifungal medications, and he recovered uneventfully. A follow-up endoscopic examination 1 year later revealed a widely patent sphenoid sinus and no evidence of fungal involvement.

[FIGURES OMITTED]

The role of fungal organisms in the pathophysiology of chronic rhinosinusitis has gained increasing attention in the recent literature. Reports of a high incidence of fungal species in specimens obtained from patients with chronic rhinosinusitis have prompted significant discussion. (2) Traditionally, descriptions of the clinical presentations of fungal sinus disease have ranged from aggressive invasive fungal sinusitis in immunocompromised hosts to more indolent forms in immunocompetent patients. Invasive fungal sinusitis is a destructive process that causes tissue necrosis and requires aggressive surgical debridement as part of treatment. Noninvasive fungal sinus disease in immunocompetent patients is generally treated successfully with conservative surgical removal of the contents of the affected sinus. (3) Noninvasive forms include sinus mycetomas and allergic fungal sinusitis.

Major criteria for the presence of allergic fungal sinusitis include nasal polyposis, evidence of IgE-mediated hypersensitivity, eosinophilic mucus, characteristic CT findings of unilateral involvement and hyperdense areas in the affected sinus, and a positive fungal culture. (4) Current treatments generally involve surgical removal of allergic mucus and drug therapy with a systemic corticosteroid. Systemic antifungals have not proven to be beneficial, although topical antifungal sprays have been suggested as a possible adjunct to treatment. (5)

References

(1.) Christmas DA, Jr., Krouse JH. Powered instrumentation in functional endoscopic sinus surgery. I: Surgical technique. Ear Nose Throat J 1996; 75:33-6, 39-40.

(2.) Ponikau JU, Sherris DA, Kern EB, et al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc 1999;74:877-84.

(3.) Bent JP III, Kuhn FA. Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg 1994;111:580-8.

(4.) Mirante JP, Krouse JH, Munier MA, Christmas DA. The role of powered instrumentation in the surgical treatment of allergic fungal sinusitis. Ear Nose Throat J 1998;77:678-80, 682.

(5.) Jen A, Kacker A, Huang C, Anand V. Fluconazole nasal spray in the treatment of allergic fungal sinusitis: A pilot study. Ear Nose Throat J 2004;83:692, 694-5.

From the Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and the Halifax Medical Center, Daytona Beach, Fla. (Dr. Mirante and Dr. Christmas), and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery, Group; the Section of Otolaryngology, Hospital of St. Raphael; and the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. Yanagisawa).
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Article Details
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Title Annotation:Rhinoscopic Clinic
Author:Yanagisawa, Eiji
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Mar 1, 2005
Words:556
Previous Article:External auditory canal polyp.
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