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CLINICAL REVIEW: Kim W Ah-See and Andrew S Evans Sinusitis and its management BMJ 2007; 334: 358-361 [Full text]

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Fungal rhinosinusitis – not to be forgotten

Suranjith L Seneviratne, Archana Herwadkar, Malini V Bhole   (18 February 2007)

Author's Response

Kim Ah-See, Andrew Evans   (20 February 2007)

Nasal Hygiene

Hugh Mann   (22 February 2007)

Fungal rhinosinusitis – not to be forgotten 18 February 2007
Suranjith L Seneviratne, Consultant Clinical Immunologist Central Manchester &Manchester Children's University Hospitals, Manchester, M13 9WL, Archana Herwadkar, Malini V Bhole Send response to journal: Re: Fungal rhinosinusitis – not to be forgotten	A review on sinusitis by Ah-See and Evans does not mention the importance of fungal rhinosinusitis (1). The published literature suggests that fungal rhinosinusitis is an important cause to bear in mind in patients with chronic rhinosinusitis (2). There are four types of fungal rhinosinusitis: allergic fungal sinusitis, mycetoma fungal sinusitis, chronic indolent sinusitis and fulminant sinusitis. Allergic fungal sinusitis (AFS) is the most common form of fungal rhinosinusitis. It is believed to be an allergic reaction to environmental fungi. Thick fungal debris and mucin are found in the sinus cavities. Causative fungi include those of the genera: Culvalaria, Bipolaris, Alternaria and Aspergillus. A study published in the Mayo Clinic Proceedings in 1999 suggested that fungal rhinosinusitis was more common than previously thought (3). The authors found that 96% of their study population had a fungus in cultures of their nasal secretions. Singh et al from India found fungal cultures to be positive in 201 (80%) of 251 patients with chronic rhinosinusitis seen at a single hospital setting (4). Present published estimates are that 5 – 10% of patients affected by chronic rhinosinusitis carry a diagnosis of AFS (2). It appears to be more common in warm humid environments (5). Treatment requires surgery and aggressive postoperative medical treatment with close follow-up. Medical treatment includes anti- inflammatory medications, allergen immunotherapy, and in many cases the addition of oral corticosteroids. Recurrence rates remain high. Mycetoma fungal sinusitis produces clumps of spores, ‘a fungal ball’ within a sinus cavity. The maxillary sinuses are most frequently involved. Treatment consists of simples scraping of the sinus cavity. Chronic indolent sinusitis is an invasive form of fungal sinusitis in patients without an identifiable immune deficiency. This form is most commonly seen in India, Sri Lanka and Sudan. Fulminant sinusitis is usually seen among immuno-compromised patients. We suggest that fungi should be included among the causes of rhinosinusitis in Box 1 of the review (1). Clinicians need to keep this condition in mind when evaluating patients with chronic rhinosinusitis as its diagnosis and treatment differs from other causes (5). 1. Ah-See KW EA. Sinusitis and its management. BMJ 2007;334:358 - 361. 2. Schubert MS. Allergic fungal sinusitis. Clin Rev Allergy Immunol 2006;30(3):205-16. 3. Ponikau JU, Sherris DA, Kern EB, Homburger HA, Frigas E, Gaffey TA, et al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc 1999;74(9):877-84. 4. Singh N, Bhalodiya NH. Allergic fungal sinusitis (AFS)--earlier diagnosis and management. J Laryngol Otol 2005;119(11):875-81. 5. Ryan MW, Marple BF. Allergic fungal rhinosinusitis: diagnosis and management. Curr Opin Otolaryngol Head Neck Surg 2007;15(1):18-22. Suranjith L Seneviratne, Archana Herwadkar: Central Manchester and Manchester Children’s University Hospitals, Manchester, UK Malini V Bhole: John Radcliffe Hospital, Oxford, UK Competing interests: None declared
Author's Response 20 February 2007
Kim Ah-See, Consultant ENT Surgeon AberdeenRoyal Infirmary, Aberdeen, AB25 2ZN, Andrew Evans Send response to journal: Re: Author's Response	We are grateful to Suranjith L Seneviratne, Archana Herwadkar and Malini V Bhole for their comments. We agree completely and would acknowledge that we perhaps should have included fungal sinusitis in this topic. In our defence we limited to article to sinusitis commonly dealt with in primary care and felt that discussion on fungal sinusitis was outwith the scope of this article and indeed could form the basis for a future review paper. We accept however that it could have been mentioned in the accompanying table. Competing interests: None declared
Nasal Hygiene 22 February 2007
Hugh Mann, Physician Eagle Rock, MO 65641 Send response to journal: Re: Nasal Hygiene	Your nose accumulates mucus, dust, bacteria, viruses, and fungi. So your nose is an ideal environment for germs and sickness. It's important to clean your nose daily. The only effective way to clean your nose is nasal irrigation. Here's the technique: Buy a package of 3-ounce cups and a salt shaker with a snap lid. Put two or three small shakes of salt in the cup, fill the cup with warm water, and stir with your finger. Too much or too little salt in the water will burn your nose. Bend over the bathroom sink, put your nose in the cup, and sniff. Don't be afraid of drowning. If the water gets in your mouth, you can just spit it out. Then blow your nose forcefully several times. Make sure you get all the water out of your nose. You'll be amazed at what comes out of your nose, and at how much better you feel. Competing interests: None declared