mykosen 21 (12) 407-411 Eingegangen am 23. Dezember 1977 @ Grosse Verlag Berlin 1978
Mycotic Sinusitis in Children Zofia LASKOWNICKA, J. KURDZIELEWICZ, Anna MACURAand Boiena OKRASI~~SKA-CHOLEWA Department of Mycology, Institute of Microbiology, Medical Academy, Krakhw, Poland (Head: Ass. Prof. P. B. HECZKO) and Silesian Center of Children Rehabilitation, Rabka, Poland (Director: Dr. H. ZIOLA)
Zusammenfassung: Bei 414 Kindern im Alter von 3 bis 15 Jahren, die a n rezidivierender schleimig-eitriger Sinusitis maxillaris und in der Mehrzahl der Fille auch an anderen Erkrankungen der Atmungsorgane litten, wurden mykologische und bakteriologische Untersuchungen durchgefuhrt. Bei 22 Kranken wurde eine schleimig-eitrige mykotische Sinusitis maxillaris und in 97 Fillen eine mykotisch-bakterielle Mischinfektion festgestellt. Die Untersuchungsergebnisse wurden vom lrlinischen Standpunkt analysiert. Summary: Mycological and bacteriological examinations were carried out in 414 children aged 3-15 years, suffering from recurrent mucopurulent sinusitis, in most cases accompanied by other respiratory diseases. 22 cases have been diagnosed as mycotic mucopurulent sinusitis and 97 as fungal and bacterial sinusitis. The results of mycotic examinations are discussed in relation to the clinical picture.
PLAIGNAUD mentioned in 1971 for the first time a possibility of fungal infection of t h e sinuses (l), b u t when GRIGORIUand DUTOITin 1973 reviewed the medical literature on this subiect they found descriptions of only 53 cases of mycotic infection of the sinuses. Recently this type of infection has been diagnosed more frequently, mainly during surgical treatment of chronic sinusitis. BAMBULEand GRIGORIU(2) described 68 cases of mycotic sinusitis in adults. Fungi belonging to species Aspersillus were reported bv them as the main etiologic factor. These authors distinguished three clinical forms of asperRillosis of the sinuses, mucopurulent, caseous and pseudotumoral. Colonization of the fungi in paranasal sinuses may occur either in the course of generalized or systemic mycosis or it may occur more frequently as an isolated focus. The main pathogens of the mycotic paranasal sinusitis are fungi such as Aspergillus, Candida a n d Mucor (4, 5, 6). Cases of mycotic sinusitis in children have been described in medical literature only occasionally (6). Material and Methods
This study was carried out in 1975 and 1976 and covered 414 children aged between 3 and 15 years. All these children suffered from recurrent niucopurulent maxillary sinuKey words: yeast-like fungi, molds, sinusitis, nystatine, amphotericine B.
Zofia LASKOVNICKA e t al.
406
sitis. Moreover most of them also had bronchial asthma, spastic bronchitis or recurrent bronchitis. All were treated before admission with various antibiotics and sulfona~nides, some also had corticosteroid drugs and therapeutic puncture of sinuses. One child had additionally undergone local application of a mixture of antibiotics into the sinuses. Materials f o r both mycological and bacteriological examinations were taken from sinuses by needle puncture and by swabbing of the larynx below the vocal cords using a laryngoscope. These examinations were performed in periods of exacerbation. The patients received no antibacterial or antimycotic drugs for a t least 3 weeks before the specimens were taken. The specimens from sinuses were examined by microscopy and by culture while the specinlens froin larynx were cultured only. Smears were Gram stained. Slants containing Sabouraud agar with 2 R glucose and supplemented with 0.5 % yeast extract were used. Two series of cultures were carried out simultaneously: one on niedia containing chloramphenicol at a concentration of 300 pginil and a second with no antibiotic. The slants were incubated a t 273 C and 37" C for 2 or 3 weeks. Isolated fungi were identified on the basis of morphology and biochemical tests using standard methods (3). Children under study were treated as follows. Drugs were administrated into sinuses by puncture every second day for 3 to 5 weeks and into the lower respiratory tract bj7 inhalations 2-3 times daily for 4 to 6 weeks. Nystatine a t a concentration of 1000 unjtsirnl in 3 % water solution of propylen glycol and aniphotericin B a t a concentration of 100 ~ g h ofl saline solution were used. I n severe cases nystatine was given orally in doses of 1.5-3.0 x lofi units per day for 3-6 weeks.
Table 1 Mycotic maxillary sinusitis (report of 22 cases) Patient
Age
Sex
Fungal Strains Sinus Secretion
No. 597175 2493/76 1835176 163/75 5501 76 508 176 3337175 3088 176 1186/75 1128175 1717/75 536176 786176 509176 3483 1 76 1724/76 1698/76 2167176 2186/75 537/76 1060176 2493175
3 14 15 13 11 10 13 9 5 11 S 8 7 6 13 12 8 7 6 10 14 9
-
Larynx
Candida sp., Penicillium sp., Trichosporon sp. Aspergillus nidulans Dematium sp. Gliocladium sp. Mucor sp. Mucor sp. Penicillium sp. Stemphylium sp. Chaetomium sp., Paeciloniyces sp., Penicillium sp, Mycelia sterilia, Penicillium sp., Scopulariopsis sp. Alternaria sp., Candida albicans Aspergillus sp., Cladosporium sp. Aspergillus fumigatus Candida albicans Candida albicans Cladosporium sp. Dematium sp. Dematium sp. Mycelia sterilin Penicillium sp. Penicillium sp. Tridiosporon sp. -
negative
negative negative negative negative negative negative negative Candida albicans Candida albicans Candida albicans Candida albicans Candida albicans Candida albicans Candida albicans Candida albicans Candida albicans Mycelia srerilia Paecilomyces sp. Candida albicans Candida albicans Candida albicans, Geotrichum sp,
mykosen 21, Heft 12 (1978)
Mycotic Sinusitis in Children
409
Table 2 Percentage Distribution of Fungal and Bacterial Findings in Sinus Maxillary Secretion and Larynx
Sinus No. 414 Larynx No. 290
Fungi + Total In Mixed Culture
Bacteria + Total In Mixed Culture
28.7
40.3
77.5
69.6
13.9
98.3
Fungi+ Bact. -
Fungi+ Bact.+
Fungi .Bact.+
73.2
5.3
23.4
54.1
17.2
94.7
0.3
48.3
50.0
1.4
FungiBact.
-
Results and Discussion Fungi without concomitant bacteria were detected in samples from sinuses of 22 children (5.3 % of all examined cases) in cultures on Sabouraud medium only. Fungi were never detected in direct microscopic observations. I n these patients the mucopurulent my cotic sinusitis inaxillaris was diagnosed. Table 1 shows differences between fungal flora recovered in cultures from sinuses and larynxes. The mycotic flora from sinuses was more abundant and variable than at isolated from laryngeal swabs. Cultures from the larynxes of 8 children did not yield fungal growth. This suggests that local mycotic foci had developed in the sinuses of children with fungal flora present. It was more difficult to interprete the results of mycological examinations in a second group comprising 97 cases (23.4 %) - Table 2. In samples taken from these children both fungi and bacteria were isolated. Therefore in these children a n i x e d myco-bacterial sinusitis maxillaris was diagnosed. As in the former group, fungi isolated from sinuses differed from those isolated from the larynx. I n the material obtained from sinuses the following bacteria concomitant fungi have been found: Staphylococcus aureus, Streptococcus viridans, Staphylococcus epidermis, less frequently Neisseria sp., Haemophilus influenzae and Diplococcus pneumoniae. Fungi in the sinuses have been found in 28.7% of all the children under study. Half of them had complex fungal flora i. e. two o r more strains from one sample were cultured. A total of 183 strains isolated from the cultures fell into 24 genera. Fungi in cultures from larynxes were found in 69.7 % of all cases, more frequently than in those from sinuses, but complex flora was isolated only from 13.9 % of the children. All 227 fungal strains cultured from larynxes fell into 10 genera. Yeast-like fungi were more freqxent than mold species. I t should be pointed out that in half the children with presence of fungi in sinuses, no fungi were found in the larynx. Simultaneous occurrence of strains belonging to same genus o r species in sinuses and larynx of the same child was observed only in 21.0 % of the cases. Negative cultures for bacteria and fungi from sinuses were found in 17.2 % and from the larynx in 1.4 % of the children. In accordance with other authors we have been able to isolate fungi more frequently in w a r m seasons of the year. However no relationship between inhabitat (town or village) and frequency of isolations of fungi was noticed, It seems that poor hygienic conditions mykosen 21, Heft 12 (1978)
Zofia LASKOWNICKA et al.
410
Table 3 Fungi Isolated From 414 Patients with Chronic Maxillary Sinusitis Number of Strains Sinus Larynx
Number of Strains Sinus Larynx Alternaria sp. Aspergillus fumigatus Aspergillus nidulans Aspergillus niger Aspergillus sp. Candida albicans Candida parapsilosis Candida rropicalis Candida sp. Cephalosporium sp. Chaetomium sp. Chrpsosporium sp. Cladosporium sp. Demarium sp. Dendrosri bella Epicoccum sp. Geotrichum sp.
2
-
9
2
1
2 18 17
2 1 1 8 2
5 12 1
1
-
6
179
2 1 2 1
1 1 -
-
Gliocladium sp. Graphium sp. Mortierella sp. Mucor sp. Mycelia sterilia Paecilomyces sp. Penicillium sp. Rhodotorula sp. Scopulariopsis sp. Stemphylium sp. Stachybotris Torulopsis glabrata Torulopsis versarilis Torulopsis sp. Tridioderma sp. Trichosporon sp.
3 1 1
8 8
5 49
3 6 1
1 1
5 I 7
9
of life, mainly humid flats have had a negative influence o n the frequency of isolations of fungi. According to our observations the clinical picture of mucopurulent mycotic sinusitis shows no specific signs different from those of bacterial sinusitis. The identification of the pathological agent can be established only on the base of mycological and/or bacteriological examinations. In most severe cases, in terms of the intensity of symptoms and persistence of the disease, a mixed flora composed of different niycotic and bacterial species was observed. Boys suffered from niycotic sinusitis more frequently than girls. Cases younger than 6 years were rare. In older children aged from 6 to 15 years no clear relationship between age a n d frequency of diagnosed mycotic sinusitis was found. According to our experience and reports of other authors the treatment of niycotic mucopurulent sinusitis is typical and does not raise particular difficulties. When niycotic infection is limited to sinuses, nystatine o r amphotericin B were instilled into sinuses. When a large quantity of mainly yeast-like fungi were found in the larynx, the antiniycotic agents were given b y inhalation and in more severe cases orally. Treatment was successful in all our cases as proved by improvement of the clinical picture of the patients and negative results of mycological examinations. Unfortunately, duc to t w o short periods of observation the relapse rate of mycotic sinusitis could not be determined. According to ARNAUD(cited after 2) t w o factors are necessary for the development of mycotic sinusitis: 1. decrease of cellular immunity as a result of preexisting chronic bacterial infection of sinuses and 2. destruction of the bacteria by intensive antibiotic therapy. A11 our children met these conditions. O u r observations are also in keeping with BAMBULE and GRIGORIU (2) who have stressed the importance of the third factor i. e. long lasting oedema of nasal mucosa which delays self clearing of sinuses and thus facilitates the installation and multiplication of fungi. Most of our patients suffered mykosen 21, Hefr 12 (1978)
Mycotic Sinusitis in Children
411
from allergic disorders of the respiratory system with marked tendency to oedematous reaction to different stimuli.
Conclusions In cases of chronic and/or recurrent sinusitis the possibility of a mycotic infection should be taken into consideration. The choice of treatment should, therefore, be preceded by bacteriological and mycological examinations of the sinuses. Acknowledgements: These investigations were supported by a grant from rhe Polish Academy of Sciences No. 10.5./05.1.2.
References 1. BAKEZ,R. D., 1971: Human infection with fungi, actinomycetes and algae. Springer Verlag New York, Heidelberg, Berlin. 7. BAMBULE, J., &L D. GRIGORIU,1976: L’ Aspergillose sinusale. Bull. SOC.Franc. Mycol. Med. 5, 161. 3 . GOLVAN,Y. J., & E. DROUHET,1972: Techniques en parasirologie et mycologie. Ed. Flammarion, Paris. 4. GRIGORIU, D., 8r M. L. DUTOIT, 1973: U n nouveau cas de sinusite maxillaire fongique. Mycopath. Mycol. appl. 51, 81. 5. HARADA,Y., 1974: Mycosis of the maxil-
lary sinus, a report of two cases. Otolaryngology (Tokyo) 46, 185. 6. JE~YNA C., , 1975: Mycotic infections with febrile status. Przegl. Pediat. 5, 151 (Polish). 7. PRINCE, H. E., & G. H. MEYER,1976: An up-to-date look a t mold allergy. Ann. Allerg. 37, 18. Address of the authors: Dr. Zofia LASKOWNICKA,Department of Mycology, Institute of Microbiology, Medical Academy, PL-31-121 Krakbw, Poland.
Nagelmykosen Onychofissan@ Onychofissan enthalt DMSO. Und DMSO sorgt dafiir, dai3 die antimykotischen Substanzen Hydroxychinolinsalicylat, Undecylensaurediathanolamid und Dichlorophen - in den Nagel eindringen und ihre Wirkung entfalten konnen. Zuranimrnsr/zung. 1 g Onychoftssan enrhalr:
B-Hydroxychinolinsalicylat UndecyJensaurediathanolamid Dichlorophen Dimethglsulfoxid
niykosen 21, Heft 12 (1978)
100 50 20 B40
mg mg mg mg
FlSSAn pharma
AnwrndxnRsgrhr/r Alle Mykosen der Zehen u n d Finger-
nagel Doirrrung und Anwcndurrgrwrrrr Soweit nichr anders ver o r d n e t , werden die erkrankren Nagel nach grundltcher Reinigung zweimal taglich eingepinrelt Die urngcbende H a u l rollre z u r v e r r n e i d u n g v o n Haurreizungen sorgfaltig abgedeckt werden
Unorrrraglrchkrri und R i i t k m Kreislauflabilitat, Lupus erythernatodes, Allergie-Anamnesen. schwere Leber u n d Nierenfunktionsstorungen. Anwendttng bei Ktndern unter 5 Jahren ParkungrgrojiFn Pinselflasche zu 10 ml D M 13.55 rn MwSt Kornbipackung rnir Firran-Pasre D M 14,83 m. MwSt z u m Abdecken Verrchreibungspflichtrg LINGNERI-FISCHER G M B H
Reg -Nr 0 601 7580 B U H L ( B A D E N )
Mycotic Sinusitis in Children Zofia LASKOWNICKA, J. KURDZIELEWICZ, Anna MACURAand Boiena OKRASI~~SKA-CHOLEWA Department of Mycology, Institute of Microbiology, Medical Academy, Krakhw, Poland (Head: Ass. Prof. P. B. HECZKO) and Silesian Center of Children Rehabilitation, Rabka, Poland (Director: Dr. H. ZIOLA)
Zusammenfassung: Bei 414 Kindern im Alter von 3 bis 15 Jahren, die a n rezidivierender schleimig-eitriger Sinusitis maxillaris und in der Mehrzahl der Fille auch an anderen Erkrankungen der Atmungsorgane litten, wurden mykologische und bakteriologische Untersuchungen durchgefuhrt. Bei 22 Kranken wurde eine schleimig-eitrige mykotische Sinusitis maxillaris und in 97 Fillen eine mykotisch-bakterielle Mischinfektion festgestellt. Die Untersuchungsergebnisse wurden vom lrlinischen Standpunkt analysiert. Summary: Mycological and bacteriological examinations were carried out in 414 children aged 3-15 years, suffering from recurrent mucopurulent sinusitis, in most cases accompanied by other respiratory diseases. 22 cases have been diagnosed as mycotic mucopurulent sinusitis and 97 as fungal and bacterial sinusitis. The results of mycotic examinations are discussed in relation to the clinical picture.
PLAIGNAUD mentioned in 1971 for the first time a possibility of fungal infection of t h e sinuses (l), b u t when GRIGORIUand DUTOITin 1973 reviewed the medical literature on this subiect they found descriptions of only 53 cases of mycotic infection of the sinuses. Recently this type of infection has been diagnosed more frequently, mainly during surgical treatment of chronic sinusitis. BAMBULEand GRIGORIU(2) described 68 cases of mycotic sinusitis in adults. Fungi belonging to species Aspersillus were reported bv them as the main etiologic factor. These authors distinguished three clinical forms of asperRillosis of the sinuses, mucopurulent, caseous and pseudotumoral. Colonization of the fungi in paranasal sinuses may occur either in the course of generalized or systemic mycosis or it may occur more frequently as an isolated focus. The main pathogens of the mycotic paranasal sinusitis are fungi such as Aspergillus, Candida a n d Mucor (4, 5, 6). Cases of mycotic sinusitis in children have been described in medical literature only occasionally (6). Material and Methods
This study was carried out in 1975 and 1976 and covered 414 children aged between 3 and 15 years. All these children suffered from recurrent niucopurulent maxillary sinuKey words: yeast-like fungi, molds, sinusitis, nystatine, amphotericine B.
Zofia LASKOVNICKA e t al.
406
sitis. Moreover most of them also had bronchial asthma, spastic bronchitis or recurrent bronchitis. All were treated before admission with various antibiotics and sulfona~nides, some also had corticosteroid drugs and therapeutic puncture of sinuses. One child had additionally undergone local application of a mixture of antibiotics into the sinuses. Materials f o r both mycological and bacteriological examinations were taken from sinuses by needle puncture and by swabbing of the larynx below the vocal cords using a laryngoscope. These examinations were performed in periods of exacerbation. The patients received no antibacterial or antimycotic drugs for a t least 3 weeks before the specimens were taken. The specimens from sinuses were examined by microscopy and by culture while the specinlens froin larynx were cultured only. Smears were Gram stained. Slants containing Sabouraud agar with 2 R glucose and supplemented with 0.5 % yeast extract were used. Two series of cultures were carried out simultaneously: one on niedia containing chloramphenicol at a concentration of 300 pginil and a second with no antibiotic. The slants were incubated a t 273 C and 37" C for 2 or 3 weeks. Isolated fungi were identified on the basis of morphology and biochemical tests using standard methods (3). Children under study were treated as follows. Drugs were administrated into sinuses by puncture every second day for 3 to 5 weeks and into the lower respiratory tract bj7 inhalations 2-3 times daily for 4 to 6 weeks. Nystatine a t a concentration of 1000 unjtsirnl in 3 % water solution of propylen glycol and aniphotericin B a t a concentration of 100 ~ g h ofl saline solution were used. I n severe cases nystatine was given orally in doses of 1.5-3.0 x lofi units per day for 3-6 weeks.
Table 1 Mycotic maxillary sinusitis (report of 22 cases) Patient
Age
Sex
Fungal Strains Sinus Secretion
No. 597175 2493/76 1835176 163/75 5501 76 508 176 3337175 3088 176 1186/75 1128175 1717/75 536176 786176 509176 3483 1 76 1724/76 1698/76 2167176 2186/75 537/76 1060176 2493175
3 14 15 13 11 10 13 9 5 11 S 8 7 6 13 12 8 7 6 10 14 9
-
Larynx
Candida sp., Penicillium sp., Trichosporon sp. Aspergillus nidulans Dematium sp. Gliocladium sp. Mucor sp. Mucor sp. Penicillium sp. Stemphylium sp. Chaetomium sp., Paeciloniyces sp., Penicillium sp, Mycelia sterilia, Penicillium sp., Scopulariopsis sp. Alternaria sp., Candida albicans Aspergillus sp., Cladosporium sp. Aspergillus fumigatus Candida albicans Candida albicans Cladosporium sp. Dematium sp. Dematium sp. Mycelia sterilin Penicillium sp. Penicillium sp. Tridiosporon sp. -
negative
negative negative negative negative negative negative negative Candida albicans Candida albicans Candida albicans Candida albicans Candida albicans Candida albicans Candida albicans Candida albicans Candida albicans Mycelia srerilia Paecilomyces sp. Candida albicans Candida albicans Candida albicans, Geotrichum sp,
mykosen 21, Heft 12 (1978)
Mycotic Sinusitis in Children
409
Table 2 Percentage Distribution of Fungal and Bacterial Findings in Sinus Maxillary Secretion and Larynx
Sinus No. 414 Larynx No. 290
Fungi + Total In Mixed Culture
Bacteria + Total In Mixed Culture
28.7
40.3
77.5
69.6
13.9
98.3
Fungi+ Bact. -
Fungi+ Bact.+
Fungi .Bact.+
73.2
5.3
23.4
54.1
17.2
94.7
0.3
48.3
50.0
1.4
FungiBact.
-
Results and Discussion Fungi without concomitant bacteria were detected in samples from sinuses of 22 children (5.3 % of all examined cases) in cultures on Sabouraud medium only. Fungi were never detected in direct microscopic observations. I n these patients the mucopurulent my cotic sinusitis inaxillaris was diagnosed. Table 1 shows differences between fungal flora recovered in cultures from sinuses and larynxes. The mycotic flora from sinuses was more abundant and variable than at isolated from laryngeal swabs. Cultures from the larynxes of 8 children did not yield fungal growth. This suggests that local mycotic foci had developed in the sinuses of children with fungal flora present. It was more difficult to interprete the results of mycological examinations in a second group comprising 97 cases (23.4 %) - Table 2. In samples taken from these children both fungi and bacteria were isolated. Therefore in these children a n i x e d myco-bacterial sinusitis maxillaris was diagnosed. As in the former group, fungi isolated from sinuses differed from those isolated from the larynx. I n the material obtained from sinuses the following bacteria concomitant fungi have been found: Staphylococcus aureus, Streptococcus viridans, Staphylococcus epidermis, less frequently Neisseria sp., Haemophilus influenzae and Diplococcus pneumoniae. Fungi in the sinuses have been found in 28.7% of all the children under study. Half of them had complex fungal flora i. e. two o r more strains from one sample were cultured. A total of 183 strains isolated from the cultures fell into 24 genera. Fungi in cultures from larynxes were found in 69.7 % of all cases, more frequently than in those from sinuses, but complex flora was isolated only from 13.9 % of the children. All 227 fungal strains cultured from larynxes fell into 10 genera. Yeast-like fungi were more freqxent than mold species. I t should be pointed out that in half the children with presence of fungi in sinuses, no fungi were found in the larynx. Simultaneous occurrence of strains belonging to same genus o r species in sinuses and larynx of the same child was observed only in 21.0 % of the cases. Negative cultures for bacteria and fungi from sinuses were found in 17.2 % and from the larynx in 1.4 % of the children. In accordance with other authors we have been able to isolate fungi more frequently in w a r m seasons of the year. However no relationship between inhabitat (town or village) and frequency of isolations of fungi was noticed, It seems that poor hygienic conditions mykosen 21, Heft 12 (1978)
Zofia LASKOWNICKA et al.
410
Table 3 Fungi Isolated From 414 Patients with Chronic Maxillary Sinusitis Number of Strains Sinus Larynx
Number of Strains Sinus Larynx Alternaria sp. Aspergillus fumigatus Aspergillus nidulans Aspergillus niger Aspergillus sp. Candida albicans Candida parapsilosis Candida rropicalis Candida sp. Cephalosporium sp. Chaetomium sp. Chrpsosporium sp. Cladosporium sp. Demarium sp. Dendrosri bella Epicoccum sp. Geotrichum sp.
2
-
9
2
1
2 18 17
2 1 1 8 2
5 12 1
1
-
6
179
2 1 2 1
1 1 -
-
Gliocladium sp. Graphium sp. Mortierella sp. Mucor sp. Mycelia sterilia Paecilomyces sp. Penicillium sp. Rhodotorula sp. Scopulariopsis sp. Stemphylium sp. Stachybotris Torulopsis glabrata Torulopsis versarilis Torulopsis sp. Tridioderma sp. Trichosporon sp.
3 1 1
8 8
5 49
3 6 1
1 1
5 I 7
9
of life, mainly humid flats have had a negative influence o n the frequency of isolations of fungi. According to our observations the clinical picture of mucopurulent mycotic sinusitis shows no specific signs different from those of bacterial sinusitis. The identification of the pathological agent can be established only on the base of mycological and/or bacteriological examinations. In most severe cases, in terms of the intensity of symptoms and persistence of the disease, a mixed flora composed of different niycotic and bacterial species was observed. Boys suffered from niycotic sinusitis more frequently than girls. Cases younger than 6 years were rare. In older children aged from 6 to 15 years no clear relationship between age a n d frequency of diagnosed mycotic sinusitis was found. According to our experience and reports of other authors the treatment of niycotic mucopurulent sinusitis is typical and does not raise particular difficulties. When niycotic infection is limited to sinuses, nystatine o r amphotericin B were instilled into sinuses. When a large quantity of mainly yeast-like fungi were found in the larynx, the antiniycotic agents were given b y inhalation and in more severe cases orally. Treatment was successful in all our cases as proved by improvement of the clinical picture of the patients and negative results of mycological examinations. Unfortunately, duc to t w o short periods of observation the relapse rate of mycotic sinusitis could not be determined. According to ARNAUD(cited after 2) t w o factors are necessary for the development of mycotic sinusitis: 1. decrease of cellular immunity as a result of preexisting chronic bacterial infection of sinuses and 2. destruction of the bacteria by intensive antibiotic therapy. A11 our children met these conditions. O u r observations are also in keeping with BAMBULE and GRIGORIU (2) who have stressed the importance of the third factor i. e. long lasting oedema of nasal mucosa which delays self clearing of sinuses and thus facilitates the installation and multiplication of fungi. Most of our patients suffered mykosen 21, Hefr 12 (1978)
Mycotic Sinusitis in Children
411
from allergic disorders of the respiratory system with marked tendency to oedematous reaction to different stimuli.
Conclusions In cases of chronic and/or recurrent sinusitis the possibility of a mycotic infection should be taken into consideration. The choice of treatment should, therefore, be preceded by bacteriological and mycological examinations of the sinuses. Acknowledgements: These investigations were supported by a grant from rhe Polish Academy of Sciences No. 10.5./05.1.2.
References 1. BAKEZ,R. D., 1971: Human infection with fungi, actinomycetes and algae. Springer Verlag New York, Heidelberg, Berlin. 7. BAMBULE, J., &L D. GRIGORIU,1976: L’ Aspergillose sinusale. Bull. SOC.Franc. Mycol. Med. 5, 161. 3 . GOLVAN,Y. J., & E. DROUHET,1972: Techniques en parasirologie et mycologie. Ed. Flammarion, Paris. 4. GRIGORIU, D., 8r M. L. DUTOIT, 1973: U n nouveau cas de sinusite maxillaire fongique. Mycopath. Mycol. appl. 51, 81. 5. HARADA,Y., 1974: Mycosis of the maxil-
lary sinus, a report of two cases. Otolaryngology (Tokyo) 46, 185. 6. JE~YNA C., , 1975: Mycotic infections with febrile status. Przegl. Pediat. 5, 151 (Polish). 7. PRINCE, H. E., & G. H. MEYER,1976: An up-to-date look a t mold allergy. Ann. Allerg. 37, 18. Address of the authors: Dr. Zofia LASKOWNICKA,Department of Mycology, Institute of Microbiology, Medical Academy, PL-31-121 Krakbw, Poland.
Nagelmykosen Onychofissan@ Onychofissan enthalt DMSO. Und DMSO sorgt dafiir, dai3 die antimykotischen Substanzen Hydroxychinolinsalicylat, Undecylensaurediathanolamid und Dichlorophen - in den Nagel eindringen und ihre Wirkung entfalten konnen. Zuranimrnsr/zung. 1 g Onychoftssan enrhalr:
B-Hydroxychinolinsalicylat UndecyJensaurediathanolamid Dichlorophen Dimethglsulfoxid
niykosen 21, Heft 12 (1978)
100 50 20 B40
mg mg mg mg
FlSSAn pharma
AnwrndxnRsgrhr/r Alle Mykosen der Zehen u n d Finger-
nagel Doirrrung und Anwcndurrgrwrrrr Soweit nichr anders ver o r d n e t , werden die erkrankren Nagel nach grundltcher Reinigung zweimal taglich eingepinrelt Die urngcbende H a u l rollre z u r v e r r n e i d u n g v o n Haurreizungen sorgfaltig abgedeckt werden
Unorrrraglrchkrri und R i i t k m Kreislauflabilitat, Lupus erythernatodes, Allergie-Anamnesen. schwere Leber u n d Nierenfunktionsstorungen. Anwendttng bei Ktndern unter 5 Jahren ParkungrgrojiFn Pinselflasche zu 10 ml D M 13.55 rn MwSt Kornbipackung rnir Firran-Pasre D M 14,83 m. MwSt z u m Abdecken Verrchreibungspflichtrg LINGNERI-FISCHER G M B H
Reg -Nr 0 601 7580 B U H L ( B A D E N )
