Original Article

FREQUENCY OF ALLERGIC INTRANASAL POLYPS AND FUNGAL SINUSITIS

IN SOUTHERN PUNJAB
1 1 2 3 2
Mirza Khizer Hameed , Muhammad Waqas Ayub , Saeed Afzal , Tehmina Munir , Luqman Satti
1
Yusra Medical & Dental College, Islamabad, Pakistan
2
Armed Forces Institute of Pathology, Rawalpindi, Pakistan
2
Army Medical College, Rawalpindi, Pakistan

ABSTRACT
Objective: To evaluate the frequency of fungal sinusitis in patients presenting with nasal polyps in Southern Punjab
areas.
Study design: Descriptive.
Place & duration of study: Department of ENT and Head-Neck Surgery Combined Military Hospital Multan from
August 2009 to July 2011.
Materials and Methods: A total of 50 immunocompetent patients with Nasal Polyps were selected. After complete
history, thorough examination and routine investigations including Serum IgE, Absolute eosinophil count and CT
scan Paranasal Sinuses (PNS), they were operated upon. Tissue removed was sent for Histopathology and Fungal
culture.
The susceptibility to antibiotics was tested using disk diffusion method with standard antimicrobial disks (Oxoid) and
adopting the method of Clinical Laboratory Standard Institute (CLSI).
Results: Male to female ratio was 1:1.7. Age range was 9 to 70 years. In 7 cases (14%) the disease was unilateral
and in 43 cases (86%) the disease was bilateral. In 35 (70%) cases the disease extended to the nose, ethmoid
sinuses & maxillary sinuses. In 13 (26%) cases the disease involved the frontal sinuses as well. In 2 (4%) cases,
the Sphenoid sinuses were also involved. Serum IgE was raised in 41 (82%) patients while Absolute eosinophil
count was raised in 47 (94%) patients. CT scan did not show bony erosions in any patient. Findings of sinusitis
were present in all the patients, while double densities were found in 29 (58%) patients. Allergic mucin was present
in 47 (94%) patients. Fungal studies were positive for Aspergillus species in 31 (62%) patients. Aspergillus flavus
was the predominant fungus being positive in 17 (55%) patients, followed by Aspergillus fumigatus in 12 (39%)
patients and Aspergillus niger in 2 (6%) patients.
Conclusion: Presence of underlying fungal sinusitis in more than 90% of the patients presenting with nasal polyps,
must raise suspicion in every case presenting with nasal polyps in the region of South Punjab. This high frequency
of underlying fungal sinusitis among patients with nasal polyps is probably due to warm and humid environment
that is conducive for growth of fungi.
Key words: Fungal sinusitis, Immuno-competent, Nasal polyps.

This article can be sited as: Hameed MK, Ayub MW, Afzal A, Munir T, Satti L. Frequency of allergic
intranasal polyps and fungal sinusitis in Southern Punjab. Pak J Pathol. 2016: 27(1): 1-6.

INTRODUCTION hypersensitivity response to inhaled fungal antigens

Allergic fungal sinusitis was recognized as an
entity since 1980s and is considered to have a strong
association with nasal polyps [1]. Katzenstein et al
had labeled this condition as ‘Allergic aspergillus
sinusitis [2], but when it was realized
dermatiaceous fungi are also responsible for it, the
disease was labeled as ‘Allergic Fungal Sinusitis
(AFS) [3]. Hot and humid climate favours AFS even
among the immunocompetent population. Initially it
was proposed to be IgE mediated Type I & III
Correspondence: Brig (Retd) Mirza Khizer Hamid, Department
of Pathology, Associate Professor in ENT, Yusra Medical &
Dental College, Islamabad, Pakistan.
Email: mirzakhizar@gmaill.com
Received: 8 Sep 2015; Revised: 7 Jan 2016; Accepted: 6 May 2016
[4], but later on it was proposed to be a T-cell
mediated response to fungal antigens [5]. Later on
some other theories made the pathogenesis more
controversial.
that
Patients present with unresponsive chronic
rhinosinusitis and nasal polyposis. Serum IgE is
found elevated in 90% of the patients and eosinophil
count is also found to be raised. CT scan PNS shows
findings of chronic sinusitis along with hetrogenous
densities due to presence of the allergic mucin. As
the disease is not invasive, usually there is no bony
erosion. Histopathology of the mucin removed shows
eosinophilia, Charcot-Leyden crystals and fungal

Pakistan Journal of Pathology 2016; Vol. 27 (1): 1-6 1

Frequency of allergic intranasal polyps and fungal sinusitis in Southern Punjab

hyphae [6]. Bent and Kuhn (1994) presented External ethmoidectomy and Caldwel-Luc’s
diagnostic criteria for AFS [7]. Presence or absence approaches depending upon the spread and extent of
of fungi does not confirm or exclude the diagnosis. the disease. The sinuses were cleaned with
Presence of allergic mucin is the most reliable hydrogen peroxide and then washed with normal
criterion for the diagnosis [8]. Its management is both saline. Nose and sinuses were packed with BIPP
medical as well as surgical. Medical management (Bismuth Iodoform Paraffin Pack) which was
includes allergen avoidance, steroid nasal sprays, removed on 5th postoperative day.
systemic antihistamines, antifungals and The polyps along with the cheesy material
immunotherapy. Surgical management is aimed at were sent for histopathology and fungal studies. The
clearance of sinuses leading to improvement in tissue removed was divided into two parts. One part
drainage [9]. Conventionally, invasive open sinus was immersed in 10% formalin for histopathological
surgical procedures like External ethmoidectomy, studies while second part was immersed in normal
fronto-ethmoidectmy and Caldwel-Luc approaches saline for fungal culture. The specimen for
are carried out but in many centers Endoscopic sinus histopathology was stained with Hematoxylin & Eosin
surgery has replaced them. stain and then examined for fungal hyphae. The
specimen for fungal culture was inoculated onto
MATERIALS AND METHODS
Sabouraud’s Dextrose Agar and incubated for up to
A descriptive study was carried out at
two weeks (Figure: 1). In growth positive samples,
Department of ENT and Head-Neck Surgery,
lactophenol cotton blue stain was prepared and
Combined Military Hospital Multan from August 2009
examined under microscope. Fungal hyphae visible
to July 2011 in collaboration with Department of
are shown in Figure: 2.
Pathology to evaluate the frequency of fungal
Patients with positive fungal culture were put
sinusitis in patients presenting with nasal polyps in
on Capsule Itraconazole 100 mg twice daily for 6
Southern Punjab areas.
months. Weekly follow up was done for 01 month,
A total of fifty cases presenting with Nasal
and then the patients were reviewed on monthly
polyps were selected by non probability sampling.
interval for one year.
Complete history was taken especially presence of
The results were analyzed for frequencies by
atopy with allergic rhinitis, asthma etc. History for any
SPSS 12.
underlying chronic disease such as Diabetese
Mellitus, malignancy etc and of intake of
RESULTS
chemotherapeutic agents and steroids was also
Male to female ratio was 1:1.7.
obtained to ascertain immune-competence. Besides
Age range was 9 to 70 years.
complete general and systemic examination,
In 7 cases (14%) the polyps were unilateral
thorough ENT and head-neck examination was
while in 43 cases (86%) they were bilateral.
carried out in all these patients. Besides routine
In 35 (70%) cases the disease extended to
laboratory investigations, Serum IgE and Absolute
the nose, ethmoid sinuses & maxillary sinuses. In 13
eosinophil count were evaluated in all these patients
(26%) cases the disease involved the frontal sinuses
and they underwent CT Scan Nose and paranasal
as well. In 2 (4%) cases, the Sphenoid sinuses were
sinuses (PNS) both axial and coronal views with
also involved.
contrast. Patients were prepared for surgery and
invasive sinus surgery was carried out adopting
Pakistan Journal of Pathology 2016; Vol. 27 (1): 1-6 2
Frequency of allergic intranasal polyps and fungal sinusitis in Southern Punjab

Serum IgE was raised in 41 (82%) patients

while Absolute eosinophil count was raised in 47
(94%) patients.
CT scan did not show bony erosions in any
patient. Findings of sinusitis were present in all the
patients, while double densities due to calcifications
were found in 29 (58%) patients (Figure-3).
Out of all, 47 (94%) cases with intranasal
polyps were found to have greenish grey sludge like
cheesy material, the mucin, filling the paranasal
sinuses. (Figure-4).
Fungal cultures were positive for Aspergillus
species in 31 (62%) patients. Aspergillus flavus was Figure-3: CT scan PNS showing double densities.
the predominant fungus being positive in 17 (55%)
patients, followed by Aspergillus fumigatus in 12
(39%) patients and Aspergillus niger in 2 (6%)
patients.
One year follow up showed recurrence of
polyps in 8 (16%) patients resulting in further surgical
intervention.

Figure-4: Greenish sludge (Mucin)

DISCUSSION
Fungal infection is considered to be the
Figure-1: Growth of aspergillus on sabourad agar.
major cause of chronic rhinosinusitis[10]. deShazo
and Swain (1995) modified the diagnostic criteria for
Allergic Fungal Sinusitis. These included presence of
sinusitis on plain X-ray PNS, identification of allergic
mucin, presence of fungal hyphae, absence of
diabetes or immunodeficiency, and absence of
invasive fungal disease[11].
AFS is described to be common in 3rd to 5th
decades with no gender predilection [12]. In our study
Figure-2: Fungal hyphae as seen under the mean age of the patients was 31 years, which is
microscope.
similar to yet another study showing age incidence to

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Frequency of allergic intranasal polyps and fungal sinusitis in Southern Punjab

be 2nd and 3rd decades with mean age of 20.75 patients respectively. These results are very similar
years [13]. Telmesani (2009) also shows an age as given in another study by Campbell & colleagues
range from 11 years to 62 years with a mean age of (2006) that showed raised IgE in 89% and
37.1 years[14]. eosinophilia in 67% of the patients [21].
In our study, male to female ratio is 1:1.7, but CT scan PNS shows signs of
Telmesani (2009) shows 33% females and 67% sinusitis, but usually in an asymmetric fashion. Three
males11, while Karthikeyan and Coumare (2010) or more sinuses are involved in most of the cases,
have described an equal sex ratio [15]. Zakirullah and ethmoids being the most commonly involved.
colleagues (2010) have described male to female Presence of hetrogenous densities due to the
ratio as 1:1.3, similar to what is in our study[16]. presence of mucin is a characteristic feature [22]. Our
Since this study is also carried out in similar results are also similar, showing involvement of
environment, that may be the reason for similarity in ethmoid and maxillary sinuses in 70% of the patients,
results. while 58% were positive for double density shadows,
Regarding laterality, our study showed the although allergic mucin was found in 94% of the
presence of bilateral disease in 86% of the patients, patients. None of the cases showed intracranial or
but Rehman and colleagues (2015) described intraorbital involvement in our study.
unilateral spread in 64% and bilateral extension in In our study, fungus culture was
36% of the patients[17]. Yet another study showed bi- positive in 62% of the patients for Aspergillus, the A.
laterality in 83% of the cases [18], very similar to the flavus species being the commonest. Manning &
results in our study. Laterality depends upon many colleagues (1991) showed positive fungal cultures in
factors including host, allergen and the environment 86% of their patients3. Many of the studies did not
factors. yield positive fungal cultures, hence they are
In our study, all the patients belonged to considered only a supportive evidence [8].
South Punjab, an area having high pollution and hot Surgery is the cornerstone of
and humid climate. Such an environment is management of these cases. We adopted
conducive for fungal sinusitis as also observed by conventional, open invasive surgical approaches
Shah and Bhalodiya (2014) in a study where 75% of including Caldwe-Luc’s and external ethmoidectomy
the patients were from such environment[19]. Since approaches, due to non-availability of sinus
similar environmental conditions exist in our north- endoscopic facilities.
western region, hence a similar incidence has been
described by Zakirullah and colleagues (2010) [16]. CONCLUSION
Unresponsive chronic rhino-sinusitis is the Presence of underlying fungal sinusitis in
usual presenting feature in most of the patients [20]. more than 90% of the patients presenting with nasal
Our study also showed similar presentation with polyps, must raise suspicion in every case presenting
persistent rhino-sinusitis and nasal obstruction in with nasal polyps in the region of South Punjab. This
almost all the patients with positive history of asthma high frequency of underlying fungal sinusitis among
in 11 (22%) patients, and of course, nasal polyps patients with nasal polyps is probably due to warm
were present in all the cases. and humid environment that is conducive for growth
Our study showed raised IgE levels and of fungi.
absolute eosinophil count in 82% and 94% of the

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Frequency of allergic intranasal polyps and fungal sinusitis in Southern Punjab

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