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Fungal sinusitis, when used loosely, can be a misleading term. It actually refers to a spectrum of fungal-associated diseases of the nose and paranasal sinuses, each with a unique presentation and management implications (Table 1). When communicating with

TABLE 1 Fungal-Associated Diseases of the Nose and Paranasal Sinuses (? is used to indicate controversy)


Immunologic status



Noninvasive forms

Allergic fungal sinusitis



Surgery, oral and topical steroids,

immunotherapy, nasal

irrigation, ? antifungals

Eosinophilic fungal

? Normal


Surgery, nasal irrigation,


topical nasal steroids, ? antifungals

Fungus ball



Surgical removal




Office removal, nasal irrigation

Invasive forms




Reversal of immunocompromise,

surgery, antifungals




Surgery, antifungals

Abbreviation: CRS, chronic rhinosinusitis.

Abbreviation: CRS, chronic rhinosinusitis.

members of the health-care team, it is important to characterize the specific manifestation of fungal sinusitis (3).

AFS is characterized by paranasal sinus inflammation, evidence of fungal-specific allergy, and the presence of allergic mucin. Histopathologic examination of allergic mucin reveals necrotic inflammatory cells and eosinophils containing Charcot-Leyden crystals along with various fungal elements. A variety of fungal species have been implicated, including Alternaria, Bipolaris, Aspergillus, and Curvalaria. Patients usually are atopic, have elevated total IgE, and demonstrate allergic responses to fungal antigen testing. A combination of endoscopic sinus surgery, systemic and topical steroids, and adjunctive immunotherapy usually results in significant relief of symptoms and can induce disease remission.

The definition of CRS set forth by the U.S. Food and Drug Administration is 12 weeks of persistent inflammation of the paranasal sinuses. As discussed in the introduction, investigators have proposed that eosinophilic fungal rhinosinusitis may account for the majority of cases of CRS. This is based on their finding of fungal elements in nearly all cases of CRS. While their hypothesis is currently being investigated, no one has conclusively demonstrated that fungi, and the immune system's response to them, are the underlying etiology of CRS.

Fungus balls are common and grow in the wet moist cavities of the paranasal sinuses irrespective of the immunologic status of the host. Some cases are asymptomatic while others mimic chronic sinusitis. They can occasionally become a source for invasive infection if the host develops an immunocompromised state. Fungus balls are usually located in the maxillary antrum. They are composed of mucin, hemorrhagic blood, and Aspergillus, Alternaria, or Mucor. Treatment consists of surgical removal and drainage.

Saprophytic fungal infections occur when fungal spores land and germinate on mucus crusts. This is commonly seen after sinonasal surgery. Treatment is simply removal of the crusts on which the fungal spores are growing.

Acute invasive fungal sinusitis occurs in patients with impaired host defenses, including patients with uncontrolled diabetes, primary or acquired immunodeficiency, or leukemia, or those on immunosuppressive therapy in the transplant setting. Histopatho-logic examination reveals fungal elements invading tissue. The typical pathogens are members of the order Mucorales. Without reversal of the immunocompromised state and prompt medical and surgical therapy, this condition is generally fatal (3).

Chronic invasive fungal sinusitis is seen in the immunocompetent patient. It is rare and usually not lethal. Aspergillus flavus accounts for many of the indolent, chronic cases of invasive fungal disease seen in Sudan. Other species include Aspergillus fumigatus, Alternaria, Pseudallescheria boydii, Sporothrix schenckii, and Bipolaris species. Histology reveals a granuloma composed of giant cells containing hyphae. In some patients, surgical exenteration is curative, while in others, the disease is persistent despite medical and surgical treatment (3).

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