Chapter 30

Fungal rhinosinusitis

basic mycology
what type of cells are fungus? Are they ubiquitous in the human body?
A few dozen species are responsible for greater than 90% of clinical infections.
What do molds produce? Describe them? These join as a colony known as what?
What are yeasts? How do they reproduce asexually? What is a chain of them known as?
What is most fungal rhinosinusitis caused by?
What do spores allow?
What three things is the development of the pathologic condition determined by?

Classification of fungal rhinosinusitis

what do classification schemes divide fungal rhinosinusitis into? This is based on what
evidence?
Describe the classification system

invasive fungal sinusitis [3]

non-invasive fungal sinusitis [3]

invasive fungal sinusitis

what do fungal elements invade? What evidence is needed for diagnosis? HYPHAL
forms within what four areas?
What separates acute from chronic disease? Which typically occur in patients that are
immunocompromised? Immunocompetent?

Acute fulminant invasive fungal sinusitis

what is the host? Especially what mediated immunity? Give three examples?
What is the clinical picture?
What is the most frequent finding? What is a sign of advanced disease?
Anesthetic regions of the face or oral cavity are particularly concerning, what may they
precede?
How does this spread- bone ___, peri____, peri_____
Endoscopy:
what should you do if you suspect this condition?
If pale or no bleeding or pain what does this suggest?
What are the most consistent physical findings? How should these be investigated in
high-risk patients?
What is the indication for biopsy?
Immunocompromised patient with altered w?
Or Signs and symptoms of ABRS Fails to improve after how long?
Where would you take biopsies from? [3]
Sites of mucosal e___? What common sites?
Radiology:
is there a pathopneumonic finding? What erosion is possible? What is the most consistent
finding? Can there be a normal CT scan?
What are the most common bugs? [4] what medium is ideal for further growth-necrotic
tissue

Treatment:
what is the most important part?
Prophylax who?
Medical -- treat what? What is been shown to be helpful in neutropenic patients? What's
is another medical treatment? Why is this a concern?
Surgical -- what's does debridement do? [4] you should debride until tissues do what?

Prognosis:
what was the previous mortality? Now?
Intracranial or orbital extension is uniformly what?
What is predictive of survival?
What is the mortality higher with as a baseline cause [2]?

Chronic invasive fungal sinusitis

what are the symptoms? Mirror what? Slowly what? Refractory to what?
Diagnosis
what is seen on scoping? What do you rarely see? What is needed to confirm the
diagnosis?
Imaging
what is done for imaging? When would you order an MRI?
Pathology
What is the pathology usually? Comment on the amount of inflammation?
Treatment
what is the treatment?
Remember to correct underlying immunologic causes , diabetes
What is needed and why? What is done?

Granulomatous invasive fungal sinusitis

this is rare where is it found?
What is the bug?
What is it virtually identical to? How is it not identical?
Occurs in what people [2]?
What does the pathology show? What distinguishes it from chronic invasive fungal
sinusitis?
What is the treatment? Plus or minus what?

Table 30.2

Non-invasive fungal sinusitis

in all three of them the fungus is entirely what?

Saprophytic fungal infestation

is this well understood?
What do they grow on? What can be done? What is useful for long-term?

Sinus fungal ball

a.k.a. what?
Describe it? It is the absence of what two things?
Clinical: refractory what ? most have what for mucosa? 10% have what?
Imaging:
what percentage have single sinus involvement? What is usually seen in the sinus?
30 to 60% have what? What percentage of bony erosion?
The presence of isolated sinus opacification on CT will prompt what?
70 to 85% of cases involve what sinus? Why is this?
Pathology
what is most common? What occurs to the surrounding mucosa? What is not present? [3]
Treatment:
what is the treatment? Endoscopic versus what? What is the recurrence rate? Are
antifungals needed?

Allergic fungal rhinosinusitis

what is it? Mucosal inflammation caused by what? What is present?
Clinical:
what is the presentation typically? Gradual what with what?
Is pain common? If it is present what does it suggest?
What can these patients rarely present with?
Sensitized individuals placed in of high fungal exposure environments show what?
Imaging:
see table 30.4
bilateral and how many cases?
Asymmetric in what percentage?
Bone erosion and extra Sino nasal extension in what percent?
What can occur for the walls ?
What do you see within the sinus? What is this likely due to?
The high protein and low water content in mucin contrasts well on what?

Immunological testing
positive to what elements?
There's a possible existence of a fungal pan antigen
what values are also often elevated? Often more than what? proposed as a clinical
indicator of what?
Histology allergic mucin
grossly thick tenacious and highly viscous what is the color ?
what does the microbiology show?
H. and E. doesn't stain what
what did they uniquely absorb? Name some stains that have this?
What is a more sensitive method for identification of fungi?
What is the histology of the mucosa?
Is fungal culture useful?
Was the diagnostic criteria?
What are the five characteristics uniformly found? [What must be seen to confirm the
diagnosis/most reliable indicator]

treatment:
what does the accumulation of mucin cause?
What are the surgical goals? What is recurrence with surgery alone?
Post op what is required?
What three things does this do?
What else can be used to prevent recurrence [2]?
Systemic steroids have significantly increased the time before what?
Systemic antifungals?

Eosinophilic fungal rhinosinusitis

what is it? What do they elicit?
Table 30.4