Functional endoscopic sinus surgery gold safe approach for patients with fungal ball
The most common form of fungal rhinosinusitis is sinonasal fungus ball which usually presents in adults with normal immunity where maxillary sinus being the most involved site. Previously, it was termed aspergillomas according to the most commonly detected fungus being Aspergillus species. Histologically, fungal ball is an accumulation of dense matter of fungal hyphae without invasion features. Patients usually present with nasal obstruction, facial pain, postnasal drip, and purulent discharge; however, others may be asymptomatic. Findings on endoscopic examination of the nasal cavity range from normal mucosa and nasal cavity to crusting edematous mucosa with polyp formation and purulent discharge. CT scans of paranasal sinuses are commonly performed. The main purpose of this study was to illustrate various presentations of paranasal sinuses fungal ball and highlighting the importance of appropriate diagnosis and treatment in such cases. Also, this study aimed to emphasize the importance of early diagnosis and treatment in such cases.
A retrospective study was carried in the otorhinolaryngology department of two hospitals: King Fahad Specialist Hospital and Qatif Central Hospital, Eastern Region, Saudi Arabia. The study was conducted on a total of 16 patients who were diagnosed with paranasal sinuses fungal ball in an 11-year period from January 2008 and November 2019.
Out of 16 patients with paranasal sinuses fungal ball, 11 cases were female and 5 males, with age ranging between 16 and 46 years. Results showed eight isolated sphenoid (50%), six isolated maxillary fungal ball (38%), one simultaneous occurrence of the sphenoid and maxillary fungal ball (6%), and one post endonasal endoscopic pituitary surgery for pituitary adenoma (6%). CT scan was performed for all 16 cases which is the standard tool for the diagnosis of the fungal ball.
Fungal rhinosinusitis (FRS) is commonly classified into invasive and noninvasive fungal rhinosinusitis based on histological tissue invasion by fungi. The invasive disease is further classified into acute invasive (fulminant) FRS, granulomatous invasive FRS, and chronic invasive FRS. On the other hand, noninvasive fungal sinusitis which is clinically behaving like chronic bacterial sinusitis. It includes 3 type saprophytic fungal infestation, fungal ball, and fungusrelated eosinophilic rhinosinusitis including allergic fungal rhinosinusitis (AFRS).
Fungal ball is chronic noninvasive accumulation and dense conglomeration fungal hyphae found in paranasal sinuses. It is important to differentiate between allergic fungal rhinosinusitis and fungal ball. AFRS is diffuse, involves bilateral sinuses, and is usually associated with nasal polyps. On the other hand, fungal ball presents unilaterally, and maxillary sinus is most affected. It is predominantly seen in immunocompetent elderly females with an average age at presentation being 64 (range 14–90) years old.
In this study, the majority of cases were females with age ranging between 16 and 46 years. Among all sinuses, the maxillary sinus is the most common site of occurrence (94%) followed by sphenoidal sinus (4–8%). The ethmoid (3%) and frontal sinus (2%) rarely occur. In study, there were six cases of maxillary, eight cases of sphenoid, one case of post endonasal endoscopic pituitary surgery, and the first reported case of simultaneous occurrence of maxillary and sphenoid sinus fungal ball. Furthermore, there was a female predominance (2 :1) ratio, as reported in our study; eleven of the cases were female, with the remaining five cases being male.
Patients with fungal balls typically present with nonspecific symptoms with various rhinological complaints that develop slowly and asymptomatically, which explains the late presentation of those cases. These symptoms vary depending on the involved sinus. In maxillary fungal ball, patients report facial pain and/or pressure, purulent rhinorrhea, nasal obstruction, and olfactory dysfunction. In this study, patients with maxillary sinus fungal ball, postnasal discharge, and facial pain were the most common complaints.
Headache, postnasal discharge, and cough are commonly observed in sphenoid fungal ball. Other symptoms include chronic cough, olfactory dysfunction, and cacosmia. Less common symptoms include convulsions, epistaxis, proptosis, fever, cough, and blurred vision. However, some patients may be asymptomatic.
In summary, appropriate diagnosis of fungal ball is crucial where specific investigations should be performed. CT scan of the PNS and nasal endoscopy with pathology are useful and highly specific in reaching the diagnosis. %e most common presenting symptoms were postnasal discharge (PND), headache, and facial pain. Functional endoscopic sinus surgery is the gold safe standard approach for patients with fungal ball aiming for fungal removal and sinus wash outs.
Source: Ali Almomen , H Albaharna,Aishah A AlGhuneem,and Batool Z AlZahir; Hindawi International Journal of Otolaryngology Volume 2022 https://doi.org/10.1155/2022/6721896
