Clinicopathological profile of fungal rhinosinusitis

Objective: To determine the clinicopathological features of fungal rhinosinusits at a tertiary care hospital. Material and Methods: This study was conducted at the Department of ENT, Head and Neck surgery, PGMI/ LRH Peshawar. This was a four years prospective study from January 2007 to December 2011. All fifty five patients were evaluated thoroughly in terms of history, examination and investigation. Biopsy of nasal mass was performed and biopsy specimens were studied by same histopathologist. After diagnosing the patient as a case of fungal rhinosinusitis surgical procedure was performed according the extent of disease. The data was analyzed using SPSS version 17. Results: These patients were in age range from 1166 years with mean age of 37.74 + S.D 16.46 years. They constitute 34 male and 21 female with male: female ratio was 1.6:1. Majority of patients (41.8%) belonged to middle age group. Most of the patients (60%) had lower socioeconomic status and mainly they were from rural area (74.54%) with only 30.9% literacy level. The commonest symptoms of these patients were nasal stuffiness (85.45%). Noninvasive fungal rhinosinusits was on top (87.27%). Aspergillus sp was the common fungal isolates (12.72%). Conclusion: Fungal rhinosinusitis is commonly affecting middle age group people. Allergic fungal rhinosinusitis is the most common entity of fungal rhinosinusitis and Aspergillus is the commonest pathogen.


Introduction:
Fungal rhinosinusitis (FRS) has been a known medical entity for several hundred years but only in more recent times the entity has been further defined. 1 Fungal infections have emerged as a world-wide health care problem in recent years. 2 Fungal rhinosinusitis may be categorized as acute, sub-acute and chronic conditions based on severity and duration of the disease specific symptom. 3n the basis of clinicopathologic evidence of tissue invasion, fungal rhinosinusitis has two major classifications: noninvasive and invasive fungal rhinosinusitis. 4There are three forms of noninvasive fungal rhinosinusitis: superficial sinonasal mycosis, allergic fungal rhinosinusitis (AFRS) (a complex entity characterized by the presence of allergic mucin with histologic similarities to those reported in Allergic Bronchopulmonary

Original Article
Bangladesh J Otorhinolaryngol 2012; 18(1): 48-54 .Aspergillosis) and fungal ball.Invasive disease is characterized as either acute or chronic based on the length the time symptoms are present before presentation. 4,5 atients with acute invasive disease are usually immunosuppressed and, by definition, present with symptoms of less than onemonth duration.This entity is characterized by the presence of fungal forms invading into the sinonasal submucosal with frequent angioinvasion and rapid intervention is necessary. 4,6Patient symptoms with fungal rhinosinusitis include nasal stuffiness, nasal discharge, facial pain, fever, and headache. 7iagnostic criteria for fungal rhinosinusitis, after specific symptoms of the disease confirmed by primary examinations are nasal endoscopy, X-ray radiography, CT and MRI. 8 Definitive diagnosis of fungal rhinosinusitis can be achieved by direct microscopically observation of dispersed samples in KOH, histo-pathological studies of dissected polyps or mucosal tissues by Hematoxylin and Eosin, Gomori's methylamine silver and periodic acid Schiff stains. 9The treatment modality for fungal rhinosinusitis includes non surgical and surgical procedures. 10e purpose of the present study was to determine the clinicopathologic findings of fungal rhinosinusitis and treatment outcome at a tertiary care hospital.

Methods:
This study was conducted at the Department of ENT, Head and Neck surgery, Post Graduate Medical Institute, Lady Reading Hospital Peshawar.This was a prospective descriptive study.The duration of the study was four years from January 2007 to December 2011.Fifty five patients were enrolled in this study.The patients of any age and either gender presented to ENT Department and diagnosed as cases of fungal rhinosinusits were included in the study.The patients who were not willing for registering in study and those who were lost from follow up were excluded from the study.A detailed history was taken; thorough examination of ENT and other systems was carried out.Besides baseline investigations CT scan and MRI were performed to know the exact sites and extent of disease.Biopsy of nasal mass was performed and biopsy specimens were studied by same histopathologist.A well informed consent was taken.The study was approved by the ethical committee of the institute.After diagnosing the patient as a case of fungal rhinosinusits surgical procedure was performed.These patients were put on antifungal treatment and they were followed for six months.The data was collected on preformed proforma and was analyzed using SPSS version 17.

Results:
In this study a total of fifty five patients were enrolled.These patients were in age range from 11-66 years with mean age of 37.74 + S.D 16.46 years.These patients constitute 34 male and 21 female with male: female ratio was 1.6:1.Majority of male patients (41.8%) belonged to the group of patients in the age range 21-40 years with mean age 31.3+S.D 5.7 years (Table-I).In this study most of the patients (60%) had lower socioeconomic status and mainly they were from rural area (74.54%) with only 30.9% literacy level (Table-II).The commonest symptoms of these patients were nasal stuffiness (85.45%), nasal discharge (72.72%) followed by facial discomfort 70.90% (Table-II).Among the diagnosis non-invasive fungal rhinosinusits was the common (87.27%) finding and allergic fungal rhinosinusits was the commonest observation (61.81%) while Aspergillus sp was the usual fungal isolates (Table-IV).

Discussion:
The diversity of fungal rhinosinusits (FRS) is highlighted by its many clinical and histopathological presentations.Clinically, FRS can be acute and chronic. 7The pathologic spectrum encompasses a variety of different entities which are classified as either invasive or non-invasive and then into specific pathologic categories which are    descriptive of clinical and histological disease processes. 9Fungal rhinosinusits can involve any age, however in our study the commonly suffered people belonged to age group 21-40 years, with mean age of 37.74 years which is consisted with study of Azar 11 having mean age of 41.9 years while it is at variance from study of Soontrapa 12 where mean age was 54.8 years.Both genders can be involved by fungal infection.In this study males were predominantly affected (61.81%) which simulates to study of Kamal 13 with male predominance (53.33%) and differs from results of Michael 14 where female outnumbered (54.50%).Forty one cases (74.54%) were from rural areas with lower socioeconomic status (60%).Most of the patients (69.1%) were illiterate and majority of them (65.45%)having symptoms lasting for less than one month duration.Similarly Kamal and collegues 13 conducted a study on sixty patients and found that 46 (76.67%) patients were from rural area whereas 14 (23.33%) were from urban area.He also observed 50% were farmers with high poverty level of 80%.The commonest clinical features in this study were nasal obstruction (85.45%), nasal discharge (72.72%) and nasal mass (47.27%) which were comparable to the features reported by Khan 15 having nasal discharge (100%), nasal obstruction (92.3%) and headache (61.5%), while these were not an agreement to the results of Soontrapa 12 where commonest features were fever (51.2%), facial pain (32.6%) and headache (25.6%).In Shrestha 16

Fig.- 3 :
Fig.-3: CT scan of nose, nasopharynx, paranasal sinuses and skull base axial and coronal views showing heterogeneous mass involving right nasal cavity, right maxillary and ethmoid sinuses with double density sign characteristic of fungal infection.

Table - I
Patients distribution in age groups with mean and standard deviation (n=55).

Table - II
Socio-demographic features of the patients (n=55).

Table - IV
Pathologic types and fungal pathogens isolated in this study (n=55).
20wever in Das18Study Aspergillus sp. was the commonest (65.8%) pathogens followed by dematiaceous sp.(9%).In Challa19report also Aspergillus sp. was the commonest etiologic agent.In Soontrapa12study the predominant pathogens were Aspergillus sp (63.1%) and Candida was 7.2%.Likewise Saravanan20disclosed that the most common culture isolate was Aspergillus flavus (n=26; 81%), followed by Aspergillus fumigatus (n=3; 9%).A Bipolaris species was isolated in only 2 patients (6%).It is concluded from this study that fungal rhinosinusitis is commonly affecting middle age group people.Allergic fungal rhinosinusitis is the commonest entity of fungal rhinosinusitis and Aspergillus is the commonest pathogen responsible for fungal rhinosinusitis.Moreover the diagnosis of fungal rhinosinusitis can be made on clinical features complemented with radiological investigations.