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Describe fungal rhinosinusitis.

ENT · 3rd Professional

Classification

Fungal rhinosinusitis is classified by whether the fungus invades the tissue, and by the speed of that invasion.
This division is not academic: it separates a same-day surgical emergency from a chronic condition treated at leisure.

Type	Features and management
Acute invasive (fulminant) — mucormycosis	An emergency. Occurs in the diabetic (especially in ketoacidosis), the neutropenic and the immunosuppressed. Angioinvasive, causing thrombosis and infarction. Look for a black eschar or pale insensitive mucosa on the turbinate or palate; facial pain, numbness, orbital signs and rapid deterioration. Treat with urgent surgical debridement, systemic amphotericin B, and correction of the ketoacidosis and immune state. Mortality is high
Chronic invasive and granulomatous	Slow invasion over months, usually aspergillus. Occurs in the mildly immunocompromised or the immunocompetent, and is reported particularly from INDIA and SUDAN. Presents as a mass mimicking a tumour, with proptosis. Needs surgery and prolonged systemic antifungal
Fungal ball (mycetoma, aspergilloma)	Non-invasive. A dense tangle of hyphae in a single sinus, the maxillary, in an immunocompetent adult, often elderly and often female. CT shows a hyperdense mass with flecks of calcification. Treated by endoscopic removal and ventilation of the sinus. NO antifungal is needed
Allergic fungal rhinosinusitis (AFRS)	Non-invasive, an IgE-mediated hypersensitivity to fungus. Young, atopic, immunocompetent patients, common in hot humid climates including INDIA. Nasal polyps with thick, tenacious, brown-green allergic mucin. Treated by surgical removal of all mucin with steroids; antifungals are not the mainstay
The key distinction	Invasive disease needs surgery and systemic antifungals urgently; non-invasive disease needs surgery and, in allergic disease, steroids — not antifungals

Allergic fungal rhinosinusitis deserves detail.
The bent and KUHN criteria — type I hypersensitivity to fungus; nasal polyposis; characteristic CT findings; eosinophilic mucin without tissue invasion; and a positive fungal stain of the mucin
CT shows characteristic hyperattenuating (bright) material within expanded sinuses, frequently with bone remodelling and thinning from pressure.
MRI shows a characteristic central signal void on T2.
The allergic mucin is the diagnostic material — thick, tenacious, brown-green, likened to peanut butter, containing eosinophils and charcot-LEYDEN crystals with scanty hyphae
Treatment is complete surgical removal of all the mucin and polyps with wide ventilation of the sinuses, followed by long-term topical and often oral steroid
Recurrence is common if any mucin is left, since it is the antigenic stimulus — so the surgery must be thorough
Immunotherapy to the relevant fungus is used in selected patients

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