Allergic Fungal Sinusitis with Mycetoma Lt Col AK Das', Gp Capt RC Kashyap', Lt Col SC Gupta', Lt Col MD Venkatesh" MJAFI 2003; 59 : 250-251
Key Words: Aspergillus; Fungal sinusitis;
1\.1~'C('toma
Introduction
F
ung a l infection o f the nose and sinuses is an uncommon condition which is now being increasingly recogni zed. It ma y occur in patients with chronic bacterial sinusitis. AIDS. prolonged usc of corticosteroids/antibiotics , uncontrolled diabetes. or an irnmunocornpromised slate . One case of Mycetoma with allergic fungal sinusitis is presented . Diagnostic features of different types of fungal s inus itis are discussed.
Case Report A ~5 year old male s hopkee pe r from Bihar. presented with le ft sided nasal obstruction . foul sme lling purulent nasal dis charge and headache of nin e months duration . Th ere wa s no hi story of s ne e z i ng. epi staxis or s te ro id admini stration. He wa s not a diabetic. He had undergone cho lecystecto my hcrniorraphy and excision of a lipoma in the back . during the past on e and a hal f years and wa s on broad spectrum antibiotics for prolonged periods. Anterior rhi noscopy re vealed muc osal edema o f the left nasal cavity associated with purulent nasal d ischarge a nd hypertrophied inferior turbinate res tricting view o f the middle meatus area . Posterior rhinoscopy showed only purulent nasal di scharge. Right nasal cavity was normal in uppcarunce. X-ray o f the paranasal sinuses revealed opacification.
Post operati ve reco very wa s une ventful. Histopathol og y o f the cheesy material revealed layers of mucu s mi xed with sheets of eosinophils and relati vely scarce fungal element s. The Mycetoma revealed den se . pure colonies of Alpergi/f/l,\' covered with fibrin and ov erlying bacterial colonies. The mucosa showed extensive ulceration. intense plasma cells. lymphocytes and eosinophil infiltration. There .....'as no invasion of fungal hyphae into the mucosa. He was reviewed four weeks later. Repeat CT scan (Fig 2) showed clear maxillary and ethmoid sinuses. an allergic th ickening of sinus mucosa and a widened ostium. He was totally symptom free. He has been prescribed steroid nasal s prays and advised regular follow up s. A six monthly re view showed no recurrence of nasal or sinus pathology.
Discussion Aspergillus species is the commonest fungal pathogen of the paranasal sinuse s r II. Hartwick and Batsakis classified sinus Aspergillosis into four types. Non invasive e xtramucosal disease which incl udes I. Allergic fungal sinus itis ")
Aspergilloma Invasive mucosal disease which includes
3.
Indolent chronic sinusitis
NCCT of the paranasal sinuses showed non homogenous soft tissue opacity in the left maxillary antrum extending into the nasal cavity and ethmoid sinus with destruction of lateral nasal wall. There "....ere hyperdense areas within the sinus and marked sclerosis of the antral walls (Fig I). Provisional diagnosis of chro nic maxillary sinusitis of the left side with possibly an arurochoanal polyp was made. Caldwell Luc 's operation was performed in the left side unde r local anaesthe sia. The s i n us wa s filled with laminations of greenish brown offen sive cheesy material of the cons istency of peanut butter (All ergic mucin) . The sinus mucosa was uniforml y hypertrophied upto one ern at plac es. all of which was removed. It ",'as during thi s process that the patient brought out a 3 em x 2 cm x I ern dirty whi te o val mas s per orally. which on careful examination turned out to be a Mycetoma ( Fun gal ball ). The natural ostium was a bnorma lly widened due to the pressure effect of the M ycet oma . An antrostom y was made for additional dependent dr ainage .
Fig. 1: Showing nnnh omogcn ou x sol'. tissue op acity in the 1..-:1'1
maxillary antrum. destruction of lateral nasal wall and double density sign
' Associate Professor. Department of Otolaryngology. 'Professor and Heud. Department of Otolaryngology. Armed Forces Medical College. Hospital. Central Command. Lucknow. Pune - 411 040. 'Classified Specialist. (ENTI. Military Hospital Jhunsi. "Classified Specialist.
Key Words: Aspergillus; Fungal sinusitis;
1\.1~'C('toma
Introduction
F
ung a l infection o f the nose and sinuses is an uncommon condition which is now being increasingly recogni zed. It ma y occur in patients with chronic bacterial sinusitis. AIDS. prolonged usc of corticosteroids/antibiotics , uncontrolled diabetes. or an irnmunocornpromised slate . One case of Mycetoma with allergic fungal sinusitis is presented . Diagnostic features of different types of fungal s inus itis are discussed.
Case Report A ~5 year old male s hopkee pe r from Bihar. presented with le ft sided nasal obstruction . foul sme lling purulent nasal dis charge and headache of nin e months duration . Th ere wa s no hi story of s ne e z i ng. epi staxis or s te ro id admini stration. He wa s not a diabetic. He had undergone cho lecystecto my hcrniorraphy and excision of a lipoma in the back . during the past on e and a hal f years and wa s on broad spectrum antibiotics for prolonged periods. Anterior rhi noscopy re vealed muc osal edema o f the left nasal cavity associated with purulent nasal d ischarge a nd hypertrophied inferior turbinate res tricting view o f the middle meatus area . Posterior rhinoscopy showed only purulent nasal di scharge. Right nasal cavity was normal in uppcarunce. X-ray o f the paranasal sinuses revealed opacification.
Post operati ve reco very wa s une ventful. Histopathol og y o f the cheesy material revealed layers of mucu s mi xed with sheets of eosinophils and relati vely scarce fungal element s. The Mycetoma revealed den se . pure colonies of Alpergi/f/l,\' covered with fibrin and ov erlying bacterial colonies. The mucosa showed extensive ulceration. intense plasma cells. lymphocytes and eosinophil infiltration. There .....'as no invasion of fungal hyphae into the mucosa. He was reviewed four weeks later. Repeat CT scan (Fig 2) showed clear maxillary and ethmoid sinuses. an allergic th ickening of sinus mucosa and a widened ostium. He was totally symptom free. He has been prescribed steroid nasal s prays and advised regular follow up s. A six monthly re view showed no recurrence of nasal or sinus pathology.
Discussion Aspergillus species is the commonest fungal pathogen of the paranasal sinuse s r II. Hartwick and Batsakis classified sinus Aspergillosis into four types. Non invasive e xtramucosal disease which incl udes I. Allergic fungal sinus itis ")
Aspergilloma Invasive mucosal disease which includes
3.
Indolent chronic sinusitis
NCCT of the paranasal sinuses showed non homogenous soft tissue opacity in the left maxillary antrum extending into the nasal cavity and ethmoid sinus with destruction of lateral nasal wall. There "....ere hyperdense areas within the sinus and marked sclerosis of the antral walls (Fig I). Provisional diagnosis of chro nic maxillary sinusitis of the left side with possibly an arurochoanal polyp was made. Caldwell Luc 's operation was performed in the left side unde r local anaesthe sia. The s i n us wa s filled with laminations of greenish brown offen sive cheesy material of the cons istency of peanut butter (All ergic mucin) . The sinus mucosa was uniforml y hypertrophied upto one ern at plac es. all of which was removed. It ",'as during thi s process that the patient brought out a 3 em x 2 cm x I ern dirty whi te o val mas s per orally. which on careful examination turned out to be a Mycetoma ( Fun gal ball ). The natural ostium was a bnorma lly widened due to the pressure effect of the M ycet oma . An antrostom y was made for additional dependent dr ainage .
Fig. 1: Showing nnnh omogcn ou x sol'. tissue op acity in the 1..-:1'1
maxillary antrum. destruction of lateral nasal wall and double density sign
' Associate Professor. Department of Otolaryngology. 'Professor and Heud. Department of Otolaryngology. Armed Forces Medical College. Hospital. Central Command. Lucknow. Pune - 411 040. 'Classified Specialist. (ENTI. Military Hospital Jhunsi. "Classified Specialist.
