12

Nasal Cavity and Paranasal Sinuses concurrent finding. maxillary sinus,afrequent noted inthecontralateral fungal sinusitis﬇.Polypsare cavity andsinusesbyallergic destruction oftheleftnasal opacification butno (Left) eosinophils). (breakdown productsof Leyden crystalsſt eosinophils withCharcot- inflammatory cellsand shows degenerated (Right) for allergicfungalsinusitis. debris, findingscharacteristic nuclear andcytoplasmic or alternatingbandsof shows "tidelines,""treerings," (Left) like consistencyoncutsection. tissue wasgreasywithaputty- with multipleprojections.The polypoid fragmentoftissue Gross photographshowsa Postoperative anti-inflammatory• therapy, including Extensive debridement• and complete evacuation of Elevated fungal-specific• IgE Peripheral eosinophilia• Polyps with putty-like• material Atopy is common (allergy)• CLINICAL ISSUES • Allergic reaction to • inhaled fungal elements ETIOLOGY/PATHOGENESIS Allergic response within• sinonasal tract mucosa Eosinophilic to fungal rhinosinusitis• (EFRS) TERMINOLOGY impacted mucin is mainstay of therapy Aspergillus eosinophils aerosolized fungal allergens, amplified and perpetu corticosteroids Radiologic imageshows Hematoxylin &eosin Hematoxylin &eosin species most common

(Right) optdTmgah cno F Gross:PolypWithPuttyAppearance Computed TomographyScanofAFS hrceitcHE"ieLns Charcot-LeydenCrystals Characteristic H&E"TideLines" Allergic Fungal Sinusitis oral ated by KEY FACTS Charcot-Leyden crystals• (degenerated eosinophils) Mycetoma• Invasive fungal sinusitis• TOP DIFFERENTIAL DIAGNOSES Gomori methenamine silver• (GMS) PAS-D easier to interpret• ANCILLARY TESTS "Tide lines," "tree rings,"• waves, or ripples of m MICROSCOPIC Muddy or greasy consistency• Putty or crunchy peanut• butter-like consistency Foul odor• MACROSCOPIC alternating with inflammatory debris ucin material 13 Nasal Cavity and Paranasal Sinuses n e l es at es cavity gG3 may ent used to provide antibiotic sensitivities antibiotic provide to used not reported females – Oral corticosteroids usually yield best outcome best yield –usually corticosteroids Oral – Functional endoscopic sinus surgery (FESS) surgery sinus – endoscopic Functional – If proptosis is present, visual disturbances are disturbances visual –present, is proptosis If – Males more likely to present with bone erosion tha erosion bone with –present to likely more Males reduce recurrences reduce therapy to yield best long-term outcome long-term best yield to therapy impacted mucin is mainstay of therapy of mainstay is mucin impacted minimum features since there is no invasive fungal infection fungal invasive no is there since ○ Medical management of allergic inflammatory diseas inflammatory allergic of ○ management Medical ○ Extensive debridement and complete evacuation of evacuation complete and ○debridement Extensive sinus involved of ○marsupialization and Polypectomy ○ Allergic desensitization (immunotherapy) ○desensitization Allergic therapy ○anti-inflammatory Postoperative itraconazole) (specifically, ○azoles Postoperative ○endoscopic be may Procedures and paranasal sinuses paranasal and prominent are erosion bony ○and expansion Orbital ○ Usually requires combination of surgery and medica and surgery of ○combination requires Usually patient of status functional to ○ problematic be Can ○ Maxillary and ethmoid sinuses most common most sinuses ○ethmoid and Maxillary proptosis and dysmorphia ○facial in result May I fungal-specific of levels ○elevated have also May ○ Results used to conduct desensitization treatments desensitization ○conduct to used Results ○ are Cultures ○distribution gender Equal IMAGING •approaches Surgical • Drugs •destruction or remodeling Bone • Bone erosion can be seen in advanced cases advanced in •seen be can erosion Bone • Expansile, sometimes destructive mass within nasal within mass destructive • sometimes Expansile, Treatment •complications risks, Options, Prognosis approach surgical and medical • integrated with Good frequency fair •with develop Recurrences Site •cavity Nasal •sinuses Paranasal Presentation •(allergy) common is Atopy rhinosinusitis • unrelenting Chronic, • Mass Tests Laboratory •eosinophilia Peripheral IgE •fungal-specific Elevated • Discharge • Rhinorrhea • Headache • Cultures performed to identify etiologic fungal ag fungal etiologic identify •to performed Cultures CT Findings CT le s ntly gies n E n are nophils nd osolized enic Allergic Fungal Sinusitis Fungal Allergic species species most common most species is uncommon agent uncommon is material Alternaria Bipolaris Curvularia Exserohilum Phialophora (ABPA) rhinosinusitis or nasal polyposis have AFS concurre AFS have polyposis nasal or rhinosinusitis (atopy), and allergic bronchopulmonary aspergillosi bronchopulmonary allergic and (atopy), – Widespread in soil, wood, and decomposing plant decomposing and –wood, soil, in Widespread – Approximately 10% of patients with chronic with –patients of 10% Approximately – Increased frequency in patients with asthma, aller asthma, with patients –in frequency Increased – – – – – Mucor Aspergillus involved in antigen presentation and immune and presentation antigen in involved response/modulation (IgE) reaction ○hypersensitivity 1 Type ○ Dematiaceous (brown-pigmented) fungi ○(brown-pigmented) Dematiaceous exposure ○ ○ ○ Allergic reaction develops in immunocompetent peop immunocompetent in ○develops reaction Allergic ○ Common ○ Class II genes in major histocompatibility complex histocompatibility ○major in genes II Class ○ Usually in 3rd to 7th decades ○7th to 3rd in Usually children in ○ seen disease a Not ○ Increased in warmer climates ○warmer in Increased possibly polyps possibly fungal allergens, amplified and perpetuated by eosi by perpetuated and amplified allergens, fungal CLINICAL ISSUES CLINICAL ETIOLOGY/PATHOGENESIS TERMINOLOGY • Tissue edema with sinus obstruction and stasis and obstruction •sinus with edema Tissue antig increased in results •fungus of Proliferation • Self-perpetuating cycle producing allergic mucin a mucin allergic producing •cycle Self-perpetuating Epidemiology Environmental Exposure Environmental Abbreviations • Incidence Pathogenesis fungi dispersed finely to •exposed is host Atopic immunoglobuli by mediated is •response Inflammatory • Allergic reaction to inhaled fungal elements fungal inhaled • to reaction Allergic Definitions aer to mucosa tract sinonasal • in response Allergic •mucin Allergic (EFRS) •rhinosinusitis fungal Eosinophilic (EMRS) •rhinosinusitis mucin Eosinophilic •rhinosinusitis fungal Allergic (HSD) •disease sinus Hypertrophic •sinusitis fungal Atopical • Allergic fungal sinusitis (AFS) •sinusitis fungal Allergic Synonyms • Sex • Age 14

Nasal Cavity and Paranasal Sinuses Concurrent sinonasal • pathology Histologic Features General Features Invasive Fungal Sinusitis Histochemistry Charcot-Leyden crystals• (degenerated eosinophils) Degenerated material • composed of neutrophils, Fungal hyphae identified• Gomori methenamine silver• (GMS) PAS-D• "Mucinous" material is• free floating, unattached Multiple t polypoid fragments• identified histologica Range: 0.1-0.4 cm fragments• of tissue Size Greasy to palpation• Muddy consistency• Putty or crunchy peanut• butter-like consistency Polypoid fragments• Foul odor• Fungal elements are often• difficult to detect (eve Significant host response• within stroma "Tide lines," "tree rings,"• waves, or ripples MICROSCOPIC MACROSCOPIC DIFFERENTIAL DIAGNOSIS ANCILLARY TESTS Respiratory epithelial○ adenomatoid hamartoma Chronic rhinosinusitis○ Sinonasal inflammatory○ polyps When fungal elements○ not identified, EMRS can be u Do not need to prove○ fungal elements are present ( special stains) Dropped sub-stage condenser○ will yield refractile Long, needle-shaped,○ or bipyramidal crystals Nuclear debris tends○ to aggregate Ghost outlines of cells○ common eosinophils, and mucinous debris Within vessel walls○ or vascular spaces within tiss Highlights fungal hyphae○ (when present) May be difficult to○ interpret due to debris Highlights fungal hyphae○ (when present) Mean overall aggregate:○ Up to 8 cm Inflammatory cells ○ are identified within tissue ra Yields overall "blue○ and pink" alternating appeara Appearance due to mucin○ material alternating with surrounding respiratory tissues instead no need to do fungal stains) appearance to crystals than floating in lumen mucin as seen with AFS inflammatory debris Polyps may show inflammation– but not abscesses or necrotic material Allergic Fungal Sinusitis o n w i t h lly ue t h e r nce i.e., sed .Bozeman S et al: Complications of allergic6. fungal 1 Marple BF: Allergic fungal21. rhinosinusitis: surgica .Thorp BD et al: Allergic fungal sinusitis5. in child 0 Mabry RL et al: Allergic20. fungal sinusitis: the rol .Aribandi M et al: Imaging features of 9. invasive and .Wise SK et al: Antigen-specific IgE in8. Thompsonsinus mucos LD: Allergic fungal sinusitis.7. Ear Nose T 9 Kuhn FA et al: Allergic19. fungal rhinosinusitis: per Generally contains minor• mucoserous glands in stro Lacks alternating pattern• 8 Ferguson BJ: Definitions18. of fungal rhinosinusitis. Do not need to prove • fungal elements are present Eosinophils ( and their• breakdown products Alternating "tide lines"• or "tree rings" Usually no host response• Fruiting heads are common• in this fungal disease Aggregation or ball of• fungi (yeasts &/or hyphae) Mycetoma Mucinous or edema material• in background mixed Polypoidwit structures with• intact surface epithelium Sinonasal Polyps .Chakrabarti A et al: Observations on 'Allergic1. fun Pathologic Interpretation Pearls .Sacks PL 4th et al: Antifungal therapy4. in the trea 7 Huchton DM: Allergic fungal17. sinusitis: an otorhino .Hall AG et al: Immunotherapy for allergic3. fungal s Dematiaceous fungi most• common 0 Ghegan MD et al: Socioeconomic10. factors in allergic 6 Schubert MS: Allergic 16. fungal sinusitis. Schubert Clin Rev MS: A Allergic 15. fungal sinusitis. Clin Aller .Laury AM et al: Chapter 7: Allergic fungal2. rhinosi 2 Mirante JP et al: Endoscopic12. view of allergic fung Kimura M et al: Usefulness11. of Fungiflora Y to dete 4 Ryan MW et al: Allergic14. fungal rhinosinusitis: dia 3 Orlandi RR et al: Microarray13. analysis of allergic SELECTED REFERENCES DIAGNOSTIC CHECKLIST need to do fungal stains) Eosinophils may be ○ seen but usually not degenerate inflammatory cells If present, can be ○ lymphohistiocytic or eosinophil Am. 45(3):631-42, viii, 2012 Otolaryngol Clin North Am. 33(2):433-40, 2000 rhinosinusitis patients. Am J Rhinol. 22(5):451-6, Otolaryngol Clin North Am. 33(2):419-33,prevention 2000 of recurrence, and role of steroids and 124(4):359-68, 2011 33(2):227-35, 2000 Clin North Am. 33(2):409-19, 2000 rhinosinusitis: a meta-analysis. Am J Rhinol Allerg Allergy Asthma Proc. 24(5):307-11, 2003 Clin Immunol. 12(6):629-34, 2012 sinusitis: a review. Radiographics. 27(5):1283-96, 16, 2006 27 Suppl 1:S26-7, 2013 under suspicion'. Med Mycol. 51(2):223-4, 2013 section of allergic mucin. Pathol Int. 57(9):613-7, bone erosion. Am J Rhinol. 21(5):560-3, 2007 Curr Opin Otolaryngol Head Neck Surg. 15(1):18-22, 13, 2007 eosinophilic mucin rhinosinusitis. Otolaryngol Head J. 86(2):74, 2007 associated with Charcot Leyden crystals e of immunotherapy. ren. Otolaryngol Clin North fungal sinusitis and gy Immunol. 20:263-71, 2007 ioperative management, l management. Otolaryngol gnosis and management. llergy Immunol. 30(3):205- tment of chronic nusitis. Am J Rhinol Allergy. 2 0 0 7 Otolaryngol Clin North Am. a of allergic fungal gal sinusitis: innocence 2008 2007 y. 26(2):141-7, 2012 al sinusitis. Ear Nose Throat inusitis. Curr Opin Allergy sinusitis. Am J Med. noninvasive fungal laryngologic perspective. ct fungus in a frozen hroat J. 90(3):106-7, 2011 antifungal agents. fungal rhinosinusitis with Neck Surg. 136(5):707- 2007 ic ma i.e., no h d o r