Download - Rhinosinusitis Jamur
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Rhinosinusitis merupakan inflamasi mukosa pada hidung dan sinus
paranasalis. Rhinosinusitis secara klinis dapat dibedakan menjadi tipe akut dan
kronis. Rhinosinusitis diklasifikasikan menjadi rhinosinusitis akut (RSA) apabila
memenuhi beberapa kriteria. Kriteria tersebut antara lain gejala yang dialami
berlangsung kurang dari 12 minggu episode akut terjadi kurang dari ! kali
pertahunnya dan mukosa yang normal kembali setelah menjalani tatalaksana
medik yang adekuat. "iagnosis rhinosinusitis akut ditegakkan apabila terdapat 2
gejala mayor atau 1 gejala minor dengan lebih dari 2 gejala minor. #ejala mayor
antara lain cairan hidung yang bersifat purulen post-nasal drip purulen , dan
batuk sedangkan gejala minor terdiri dari sakit kepala nyeri pada $ajah edema
periorbital nyeri telinga halitosis nyeri gigi nyeri tenggorok oeningkatan
wheezing dan demam. Rhinosinusitis dikatakan kronis apabila berlangsung
selama lebih dari 12 minggu dengan episode akut lebih dari ! kali pertahun dan
re%ersibilitas mukosa yang abnormal setelah terapi yang adekuat.
Sumber&
Afifah ' Said . Rinosinusitis dalam& *anto +hris editor. Kapita selektakedokteran. ,akarta& -edia Aesculapius d. ! 2/1!0 1/!3.
Aring A- +han -- Acute Rhinosinusitis in Adults. American family physician.
2/11 -ay& 4ol 56 (3)& 1/786.
Sesuai anatomi sinus yang terkena sinusitis dapat dibagi menjadi sinusitis
maksila sinusitis etmoid sinusitis frontal dan sinusitis sfenoid. 9ilamengenai
beberapa sinus disebut multisinusitis sedangkan bila mengenai semua sinus
paranasal disebut pansinusitis (-angunkusumo dan Rifki 2///).
Sumber& -angunkusumo Rifki '. Sinusitis dalam& Soepardi A :skandar '
(editor). 9uku Ajar :lmu Kesehatan *elinga idung *enggorokan Kepala ;eher.
disi ke7. ,akarta. 9alai
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:nfeksi pada hidung dapat mengenai hidung luar yaitu bagian kulit hidung
dan ongga dalam hidung yaitu bagian mukosanya. Rhinitis ditandai dengan
adanya proses inflamasi mukosa hidung yang dapat disebabkan oleh infeksi
alergi atau iritasi.1 Rhinitis dapat terjadi bersamaan dengan sinusitis dikarenakan
mukosa dari hidung masih terhubung ke sinus paranasalis.12 Angka kejadia
rhinosinusitis jamur meningkat dengan meningkatnya pemakaian antibiotik
kortikosteroid obatobat imunosupresan dan radioterapi.6
-angunkusumo dkk. menuliskan bah$a jenis jamur yang paling sering
menyebabkan infeksi pada daerah sinus paranasal adalah Aspergillus dan
+andida.6 9erbeda dengan Adams dkk. yang menyatakan bah$a +andida sp.
jarang menyerang hidung. Aspergilosis seringkali terjadi sebagai penyakit paru
kronik namun dapat pula sebagai infeksi granulomatosa kronik pada sinus
paranasalis hidung telinga tengah dan liang telinga.!
Rhinosinusitis dapat diklasifikasikan berdasakan sifatnya menjadi
rhinosinusitis jamur in%asif dan rhinosinusitis jamur nonin%asif. Rhinitis jamur
nonin%asif dapat menyerupai rhinolit dengan inflamasi mukosa yang lebih berat.
Rhinolit pada rhinosinusitis jamur sebenarnya merupakan gumpalan jamur
( fungus ball ). Rhinosinusitis jamur yang bersifat in%asif ditandai dengan
ditemukannya hifa jamur pada lamina propria. :n%asi jamur apabila terjadi hingga
lapisan submukosa dapat menyebabkan perforasi septum.1
*erapi yang diberikan pada rhinosinusitis jamur nonin%asif adalah dengan
mengangkat seluruh gumpalan jamur. bat yang diberikan antara lain amfoterisin 9 yang
terkadang diberikan bersama rifampisin atau flusitosin agar lebih efektif.6
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Sumber&
1. ?ardani RS -angunkusumo . :nfeksi idung dalam& Soepardi A dkk (editor). 9uku Ajar :lmu Kesehatan *elinga idung *enggorokan Kepala
;eher. disi ke. ,akarta. 9alai
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(minimal 2 minggu pemberian) dan dilakukan sebelum terapi
pembedahan sinus) serta nasoendoskopi dan siskopi (bila tersedia).
Kriteria rujukan
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Aial +* scan of sinuses sho$s a right fungal maillary sinusitis $ith an epanding mass
(possibly aspergillosis).
History of the Procedure
=ungal infections of the paranasal sinuses are uncommon and usually occur in
indi%iduals $ho are immunocompromised. o$e%er recently the occurrence of
fungal sinusitis has increased in the immunocompetent population.
*he most common pathogens are from Aspergillus and Mucor species.
Aspergillosis can cause nonin%asi%e or in%asi%e infections. :n%asi%e infections are
characteriDed by dark thick greasy material found in the sinuses. :n%asi%e
infections can cause tissue in%asion and destruction of adjacent structures (eg
orbit +'S). 'onin%asi%e infections cause symptoms of sinusitis and the sinus
in%ol%ed is opacified on radiographic studies. Routine cultures from the sinuses
rarely demonstrate the fungus. o$e%er the fungus is usually suspected upon
re%ie$ing the +* scan result and is detected on remo%al of the secretions from the
sinus.
Problem
=ungal infections of the paranasal sinus can manifest as 2 distinct entities.
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*he more serious infection commonly occurs in patients $ith diabetes or in
indi%iduals $ho are immunocompromised and is characteriDed by its
in%asi%eness tissue destruction and rapid onset. arly detection and treatment are
%ital for these infections because of the high mortality rate.
'onin%asi%e infections are chronic and are usually treated for etended periods
aschronic sinusitis before the condition is recogniDed.
Etiology
Noninvasive fungal sinusitis
*$o forms are described in this category& allergic fungal sinusitis and sinus
mycetoma@ball.
-ost commonly Curvularia lunata, Aspergillus fumigatus, and Bipolaris and
Drechslera species cause allergic fungal sinusitis.
A fumigatus and dematiaceous fungi most commonly cause sinus mycetoma.
A study by ;u-yers et al found that socioeconomic factors differed bet$een
patients $ith allergic fungal rhinosinusitis and those $ith chronic rhinosinusitis
$ith the latter tending to be $hite and older $ith a higher income and greater
access to primary care. *he study $hich in%ol%ed a total of 15 patients (36
patients in each group) also found that patients $ith allergic fungal rhinosinusitis
tended to ha%e greater Euantitati%e serum immunoglobulin (:g) le%els and
higher ;und-ackay scale scores than did patients $ith chronic rhinosinusitis. B!C
nvasive fungal sinusitis
:n%asi%e fungal sinusitis includes the acute fulminant type $hich has a high
mortality rate if not recogniDed early and treated aggressi%ely and the chronic and
granulomatous types.
http://emedicine.medscape.com/article/232791-overviewhttp://emedicine.medscape.com/article/834401-overviewhttp://emedicine.medscape.com/article/232791-overviewhttp://emedicine.medscape.com/article/834401-overview
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Saprophytic fungi of the order -ucorales including Rhizopus ,Rhizomucor,
Absidia, Mucor, Cunning hamella, Mortierella ,Sasenaea, and
Apoph!som!ces species cause acute in%asi%e fungal sinusitis.
A fumigatus is the only fungus associated $ith chronic in%asi%e fungal sinusitis.
Aspergillus flavus eclusi%ely has been associated $ith granulomatous in%asi%e
fungal sinusitis.
Patho!hysiology
"llergic fungal sinusitis
Allergic rhinitis is pre%alent in this group and is considered to be the trigger
mechanism behind allergic fungal sinusitis.
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diagnosis. +* scanning of the sinuses re%eals opacification $ith concretions
and@or calcifications.
Sinus mycetoma
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ndications
*he treatment of choice for all types of fungal sinusitis is surgical (see Surgicaltherapy).
%elevant "natomy
See Surgical therapy.
#ontraindications
All forms of fungal sinusitis reEuire surgical treatment. *he only contraindications
to surgical management relate to the general condition of the patient. 9efore
surgery is recommended risks and benefits of the surgical procedure should be
$eighed against the risks of general anesthesia.
&aboratory Studies
See the list belo$&
• le%ated total fungusspecific :g concentrations are often found in
patients $ith allergic fungal sinusitis. *his is less common in patients $ith
sinus mycetoma.
• sing enDymelinked immunosorbent assays one study eamined the
sinonasal tissue and secretions in patients $ith chronic rhinosinusitis for
the presence of mycotoins (ie aflatoin deoyni%alenol Dearalenone
ochratoin and fumonisin) to determine their possible role if any in
chronic rhinosinusitis. 'o mycotoins $ere found ecept ochratoin in !
of 15 samples. *he clinical significance of these results has not been
determined. B8C
• -iddlebrooks et al de%ised a se%en%ariable computed tomography (+*)
scanFbased diagnostic model for acute in%asi%e fungal rhinosinusitis. *hey
reported that an abnormality associated $ith one of the modelGs %ariables
H$hich consist of periantral fat bone dehiscence orbital in%asion septal
ulceration the pterygopalatine fossa the nasolacrimal duct and the
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lacrimal sacHhas a positi%e predicti%e %alue of 58I a negati%e predicti%e
%alue of 37I a sensiti%ity of 37I and a specificity of 5I $hile the
in%ol%ement of t$o %ariables gi%es the model a specificity of 1//I and a
positi%e predicti%e %alue of 1//I.B5C
maging Studies
See the list belo$&
• +* scanning of the paranasal sinuses in the coronal %ie$s is essential in
the e%aluation of patients in $hom fungal sinusitis is suspected. B3 1/C• -R: $ith enhancement may be helpful in assessing patients $ith allergic
fungal sinusitis and in patients in $hom in%asi%e fungal sinusitis is
suspected. B1/C
• -R: may sho$ lo$ signal intensity suggesting a fungal process %ersus a
solid mass in allergic fungal sinusitis.
• -R: is helpful in e%aluating +'S spread in in%asi%e fungal sinusitis.
Histologic Findings
:n allergic fungal sinusitis allergic mucin contains intact and degenerated
eosinophils +harcot;eyden crystals cellular debris and sparse hyphae. *he
sinus mucosa has mied cellular infiltrate of eosinophils plasma cells and
lymphocytes. *he mucus membrane is not in%aded by fungi.
'o allergic mucin is present in sinus mycetoma. o$e%er the sinus contains
dense material that consists of hyphae separate from but adjacent to the mucosa.
*he sinus mucosa is not in%aded.
istopathologic studies in acute in%asi%e fungal sinusitis re%eal hyphal in%asion
of the mucosa submucosa and blood %essels including the carotid arteries and
ca%ernous sinuses0 %asculitis $ith thrombosis0 hemorrhage0 and tissue infarction.
'ecrosis of the mucosa submucosa and blood %essels $ith lo$grade
inflammation is obser%ed in chronic in%asi%e fungal sinusitis.
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#ranuloma $ith multinucleated giant cells $ith pressure necrosis and erosion is
obser%ed in granulomatous in%asi%e fungal sinusitis.
'edical (hera!y
*he treatment of choice for all types of fungal sinusitis is surgical. -edical
treatment depends on the type of infection and the presence of in%asion.
"llergic fungal sinusitis
*he treatment of choice is generally surgery. Systemic steroids may be indicated
once surgery is performed and the diagnosis is confirmed. Some authors suggest alo$ dose of prednisone (/.7 mg@kg) in a tapering dose $ith alternateday dosage
o%er a 6month period. *opical nasal steroids are helpful postoperati%ely.
Aggressi%e nasal salt$ater $ashes are recommended. :mmune therapy for
specific allergens is contro%ersial e%en though some reports suggest benefit from
this treatment. Systemic antifungals are not indicated in the absence of in%asion.
Sinus mycetoma
*he recommended treatment is surgical. >nce the fungus ball is remo%ed no
further medical treatment is indicated ecept for the underlying condition. 'o
antifungal treatment is necessary.
#hronic invasive fungal sinusitis
Surgical treatment is mandatory. :nitiate medical treatment $ith systemic
antifungals once in%asion is diagnosed. Amphotericin 9 (2 g@d) is recommended0
this can be replaced by ketoconaDole or itraconaDole once the disease is under
control.
A study by -ehta et al suggested that itraconaDole may be as effecti%e as
amphotericin 9 in the treatment of chronic in%asi%e fungal sinusitis. :n a
prospecti%e randomiDed unblinded study of 2 immunocompetent patients one
group (1/ patients) $as treated $ith amphotericin 9 and the other (1 patients)$ith itraconaDole. A complete cure $as achie%ed in t$o patients in the
amphotericin9 group and fi%e in the itraconaDole group $hile four
amphotericin9 patients and se%en itraconaDole patients eperienced persistent
disease and one amphotericin9 patient and three itraconaDole patients had
relapses. :n addition three patients died and one $as lost to follo$up. 9ased on
relati%e risk analysis the in%estigators concluded that itraconaDole and
amphotericin 9 $orked eEually $ell against chronic in%asi%e fungal sinusitis.B11C
"cute invasive fungal sinusitis
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mergent treatment is necessary once this condition is suspected. :nitiate systemic
antifungal treatment after surgical debridement. igh doses of amphotericin 9 (1
1.7 mg@kg@d) are recommended. >ral itraconaDole (!// mg@d) can replaceamphotericin 9 once the acute stage has passed. *reatment of the underlying
immune deficiency if possible is desirable.
#hronic granulomatous fungal sinusitis
Surgical debridement is the mainstay of treatment follo$ed by systemic
antifungal medications. Recurrence of this condition is rare.
Surgical *herapy
"llergic fungal sinusitis
Surgery is generally considered the treatment of choice. #oals of surgical therapy
are conser%ati%e debridement of the allergic mucin and polyps (if present) from
the in%ol%ed sinuses and restoration of sinus aeration. #oals may be achie%ed
endoscopically if possible. An eternal approach can be considered if the lesion is
not accessible endoscopically. AdeEuate %entilation of the sinus is essential to
pre%ent relapse or recurrence of the disease once the disease is eenterated.
Sinus mycetoma
Surgical remo%al of the fungus ball $ith aeration of the sinus is the only
reEuirement. >nce this is accomplished no further medical treatment is indicated
ecept for the underlying condition. ndoscopic lesion remo%al can be performed
$hen the lesion is accessible. +onsider an eternal approach in patients in $hom
the mycetoma cannot be remo%ed endoscopically.
"cute invasive fungal sinusitis
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Follo)*u!
"llergic fungal sinusitis
;ongterm follo$up care is reEuired for maintenance of the sinus ca%ities0 this
may be achie%ed %ia endoscopic eamination and debridement in the office. A
short course of systemic steroids may be readministered if any signs of relapse or
recurrence are seen. Surgical debridement may be necessary if systemic steroids
fail to control the disease.
Sinus mycetoma
;ongterm follo$up care is not reEuired once the lesions are healed and patency
of the sinuses is maintained.
"cute invasive fungal sinusitis
*his condition is rare and is usually associated $ith a high mortality rate.
Sur%i%ors may ha%e facial deformities and reEuire longterm follo$up care by
se%eral specialists including head and neck surgeons infectiousdisease
specialists and immunodeficiency specialists.
#hronic invasive fungal sinusitis
*his condition tends to recur. *herefore longterm follo$up care is
recommended.
#hronic granulomatous fungal sinusitis
perience $ith this condition is limited.
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necrosis. +a%ernous sinus thrombosis and in%asion of the +'S are common and
carry a mortality rate of 7/5/I.
#hronic invasive fungal sinusitis
:n%asion into adjacent structures is not as common as in the acute type. o$e%er
erosion into the orbit or +'S is likely if the disease is left untreated.
#hronic granulomatous fungal sinusitis
rosion into the adjacent structures (eg orbit +'S) is likely. :nitiate aggressi%e
therapy to a%oid erosion.
+utcome and Prognosis
"llergic fungal sinusitis
*his disorder carries a good prognosis follo$ing adeEuate surgical debridement
and aeration of the sinuses. +lose follo$up care is important. ;ongterm use of
topical steroids controls relapses. Shortterm systemic steroids may be reEuired
$hen relapses occur.
Sinus mycetoma
*his condition has an ecellent prognosis once the fungus ball is remo%ed andadeEuate aeration of the sinus is restored. 'o longterm follo$up care is reEuired
for most patients.
"cute invasive fungal sinusitis
*his condition carries a poor prognosis. -ortality rate is reported at 7/I e%en
$ith aggressi%e surgical and medical treatment. Relapses are common during
subseEuent episodes of neutropenia. *reatment $ith systemic antifungals as
prophylais is indicated in cases of neutropenia.
#hronic invasive fungal sinusitis
#ood prognosis has been noted in patients $ho recei%e a prolonged course of
systemic antifungals.
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1. ussain S Salahuddin ' Ahmad : Salahuddin : ,ooma R. Rhinocerebral
in%asi%e mycosis& occurrence in immunocompetent indi%iduals. ur ,
Radiol. 1337 ,ul. 2/(2)&1717. B-edlineC.2. Scharf ,; Soliman A-. +hronic rhiDopus in%asi%e fungal rhinosinusitis in
an immunocompetent host. ;aryngoscope. 2//! Sep. 11!(3)&17667.
B-edlineC.
6. SiddiEui AA Shah AA 9ashir S. +raniocerebral aspergillosis of
sinonasal origin in immunocompetent patients& clinical spectrum and
outcome in 27 cases. 'eurosurgery. 2//! Sep. 77(6)&/2110 discussion
116. B-edlineC.
!. ;u-yers J "eal A- -iller ," et al. +omparison of Socioeconomic
and "emographic =actors in tolaryngol ead 'eck Surg. 2/17 Apr
28. B-edlineC.7. tolaryngol ead 'eck Surg. 2/16 Aug. 7&2553!. B-edlineC.
B=ull *etC.12. ?allace "4 "yke$icD -S 9ernstein ": et al. *he diagnosis and
management of rhinitis& an updated practice parameter. , Allergy +lin
:mmunol. 2//5 Aug. 122(2 Suppl)&S15!. B-edlineC.
16. Anselmo;ima ?* ;opes R
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1. deShaDo R" >L9rien - +hapin K SotoAguilar - #ardner ; S$ain R.
A ne$ classification and diagnostic criteria for in%asi%e fungal sinusitis.
Arch >tolaryngol ead 'eck Surg. 1338 'o%. 126(11)&11515. B-edlineC.18. #illespie -9 >L-alley 9? ,r =rancis ?. An approach to fulminant
in%asi%e fungal rhinosinusitis in the immunocompromised host. Arch
>tolaryngol ead 'eck Surg. 1335 -ay. 12!(7)&72/. B-edlineC.
15. #osepath , -ann ?,. Role of fungus in eosinophilic sinusitis. +urr >pin
>tolaryngol ead 'eck Surg. 2//7 =eb. 16(1)&316. B-edlineC.
13. ,ahrsdoerfer RA jercito 4S ,ohns -- +antrell R? Sydnor ,9.
Aspergillosis of the nose and paranasal sinuses. Am , >tolaryngol. 1383
=all. 1(1)&1!. B-edlineC.
2/. ;ansford 9K 9o$er +- Seibert R?. :n%asi%e fungal sinusitis in the
immunocompromised pediatric patient. ar 'ose *hroat ,. 1337 Aug.
8!(5)&786. B-edlineC.21. >chi ,? arris ,tolaryngol ead 'eck Surg. 2//! 'o%.
161(7)&8/!1/. B-edlineC.
28. ?ashburn R#. =ungal sinusitis. +urr +lin *op :nfect "is. 1335. 15&/8!.
B-edlineC.25. ?ise SK 4enkatraman # ?ise ,+ "el#audio ,-. thnic and gender
differences in bone erosion in allergic fungal sinusitis. Am , Rhinol. 2//!
'o%"ec. 15()&638!/!. B-edlineC.
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Fungal rhinosinusitis refers to a broad group of conditions caused by fungal
infections of the paranasal sinuses.
Fungus Ball
In this condition, an isolated paranasal sinus is completed filled with a ball of fungal
debris, most frequently in the maxillary sinuses. Patient symptoms include fullness,
pressure and discharge. Treatment for a fungus ball requires surgery for complete
removal of all fungal elements. The prognosis is good.
llergic Fungal !hinosinusitis
llergic fungal rhinosinusitis "F!#$ is characteri%ed by it the sinus secretions, which
have a characteristic golden&yellow color and have a consistency li'e rubber cement.
These secretions contain proteins from degranulated eosinophils "a type of
inflammatory cell$ plus some fungal elements. Patients often will have received
multiple treatments "including steroids$ for chronic rhinosinusitis before the diagnosis
of F!# is confirmed. (any F!# patients also have asthma. )ndoscopic sinus
surgery is required for diagnosis and mechanical cleansing of the sinuses, but
surgery must be combined with long&term medical management. (edical sinus
infection treatments include systemic and topical corticosteroids and antifungals as
well as antibiotics for bacterial infection.
cute Fulminant Fungal !hinosinusitis
cute fulminant invasive rhinosinusitis "also 'now as rhinocerebral mucormycosis or
simply *mucor+$ occurs when fungal organisms invade the sinus tissues in patients
who are immunosuppressed. lassically, these patients have suppressed immune
systems due to chemotherapy administered for cancer treatment, or they have
diabetes which leads to immune suppression. In the early stages, patients have an
area of necrotic tissue "i.e., dead tissue due to invasion by the fungus$ within the
sinuses, but within hours, it can rapidly progress to eye and brain involvement.
Prognosis is poor. )mergency surgery is necessary to confirm the diagnosis and to
mechanically remove all dead tissue. #ystemic antifungal treatment is also provided.
If possible, the efforts to reverse the underlying immune suppression should be
initiated.
hronic Invasive Fungal !hinosinusitis
In chronic invasive fungal rhinosinusitis, the process of invasion of the sinus tissues
occurs over a period of wee's or months, rather than hours. (any patients with this
relatively rare condition have subtle abnormalities in their immune system due to
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diabetes or chronic steroid use. Patients can present with eye swelling and
blindness. -rgent surgery is necessary to confirm the diagnosis and to remove all
involved tissues. gain, systemic antifungal treatments are also critically important.
ranulomatous Fungal !hinosinusitis
The onset of granulomatous fungal rhinosinusitis is also gradual. This condition is
characteri%ed by a specific long&term inflammatory response, 'nown as
granulomatous inflammation to fungal organisms that have invaded the sinus tissues.
lmost all cases occur in the #udan and neighboring countries.
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FUNGAL SINUSITIS
/evyani 0al, (/.
INTRODUCTION
Fungus is ubiquitous, present in all our surroundings and the air we inhale. (ost
healthy people do not react to the presence of fungus due to a functioning immune
system. 1owever, in rare instances, fungus may cause inflammation in the nose and
the sinuses. Fungal sinusitis can come in many forms, differing in pathology,
symptoms, course, severity and the treatment required. It is broadly classified into
invasive and non&invasive types.
simplified classification of fungal sinusitis is as follows2
. 3on&invasive fungal sinusitis
i. Fungus ball
ii. llergic fungal sinusitis
iii. 3on&allergic fungal sinusitis
B. Invasive fungal sinusitis
i. cute invasive fungal sinusitis
ii. hronic invasive fungal sinusitis
iii. ranulomatous invasive fungal sinusitis
NON-INVASIVE FUNGAL SINUSITIS
Fungus Ball2 This is a non&invasive form of fungal sinusitis. In essence, there isan overgrowth of fungal elements in the sinuses. (ost commonly molds suchas Aspergillus are responsible. The most commonly involved sinuses arethe maxillary and the sphenoid sinuses, where the fungus finds favorable conditionssuch as warmth and humidity for growth. #ometimes, bacteria can cause super&added infection in the sinus affected by the fungus ball. Typically, only a single sinusis involved, and the disease has a classic appearance on T or (!I scans.Treatment involves removal of the fungus ball through endoscopic sinus surgery.-sually a peanut&butter li'e appearance of the fungal ball is noted. (ost patientshave excellent results from surgery, and may not require any further treatment.
http://care.american-rhinologic.org/nasal_anatomyhttp://care.american-rhinologic.org/nasal_anatomyhttp://care.american-rhinologic.org/nasal_anatomyhttp://care.american-rhinologic.org/sinus_anatomyhttp://care.american-rhinologic.org/sinus_anatomyhttp://care.american-rhinologic.org/sinus_anatomyhttp://care.american-rhinologic.org/nasal_anatomyhttp://care.american-rhinologic.org/sinus_anatomyhttp://care.american-rhinologic.org/sinus_anatomy
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llergic Fungal #inusitis "F#$2 llergic Fungal #inusitis "F#$2 Patients withallergy to certain fungi may develop allergic fungal sinusitis. ommon fungi belongingto the /ematiaceous family are usually involved in F#. These include lternaria,Bipolaris and urvularia species. The presence of fungus in the sinuses causes anallergic response, resulting in production of allergic mucin and nasal polyps. -sually,the disease affects more than one sinus on one side. 1owever, all sinuses on bothsides may be involved in severe cases. Patients have a typical appearance on nasalendoscopy with the presence of allergic mucin and polyps. llergy testing to fungi ispositive. #inus T scans also have a typical appearance. Tissue examination underthe microscope shows allergic mucin containing fungal elements without tissueinvasion. Treatment involves endoscopic sinus surgery to clear polyps and allergicmucin, and to restore the ventilation and drainage of sinuses. This has to becombined with aggressive medical therapy with corticosteroids which can be usednasally and4 or systemically. Patients may also benefit from treatment of allergywith immunotherapy "allergy shots or drops$ and antihistamines. nti&fungaltreatment is usually not required, as it is the reaction to the fungus that needs to bemodulated. 1owever, in severe recurrent disease, anti&fungal therapy may beneeded.
http://care.american-rhinologic.org/immunotherapyhttp://care.american-rhinologic.org/immunotherapyhttp://care.american-rhinologic.org/immunotherapy
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3on&allergic fungal sinusitis2 In some instances, mucin and fungus may beidentified in patients with sinusitis in the absence of any allergy to fungus. Fungusmay also be found in the sinuses of patients that have had previous surgery. 5hether these fungi are innocent bystanders or are the cause of sinus disease is currentlyunder investigation and a sub6ect of great debate.
INVASIVE FUNGAL SINUSITIS
cute Invasive Fungal #inusitis2 This is the most dangerous and life&threatening form of fungal sinusitis. Fortunately, it is very rare, and usually onlyaffects severely immunocompromised patients "people whose immune systems don7t
wor' properly$. These include patients with leu'emia, aplastic anemia, uncontrolleddiabetes mellitus, and hemochromatosis. Patients undergoing anti&cancerchemotherapy or organ4 bone&marrow transplantation are especially susceptible. spergillus or members of the class 8ygomycetes "(ucor, !hi%opus$ are the mostfrequent causative agents. The disease has an aggressive course, with fungusrapidly growing through sinus tissue and bone to extend into the surrounding areas of the brain and eye. )ndoscopically, "meaning when we loo' with a small scope in thenose$ areas of dead tissue and eschar are noted. (icroscopic examination showsinvasion of blood vessels by the fungus, causing tissue to die. Treatment involves acombination of aggressive surgical and medical therapy. !epeated surgery may benecessary to remove all dead tissue. (edications such as anti&fungal drugs andthose that help restore the immune status of the patient are 'ey to improving survival,
as this disease is frequently fatal.
http://care.american-rhinologic.org/nasal_endoscopyhttp://care.american-rhinologic.org/nasal_endoscopyhttp://care.american-rhinologic.org/nasal_endoscopy
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hronic invasive fungal sinus2 -nli'e acute invasive fungal sinusitis whosetypical course is less than 9 wee's "and can actually progress over hours and days$,chronic invasive fungal sinusitis is a slower destructive process. The disease causesrare vascular invasion, sparse inflammatory reaction and limited involvement of surrounding structures. It is usually seen in patients with I/#, diabetes mellitus or chronic corticosteroid treatment. The disease most commonly affects the ethmoidand sphenoid sinuses, but may involve any sinus. The typical time course of thedisease is over : months. Tissue cultures show fungus in over half the patients, and spergillus fumigatus is the most commonly grown fungus. Treatment involvessurgery in combination with medical therapy "anti&fungal drugs and measures torestore the patient7s immune system$.
ranulomatous invasive fungal sinusitis2 This form of fungal sinusitis israre in the -nited #tates. It is usually seen in patients from #udan, India, Pa'istanand #audi rabia. Patients have normal immune status. The disease has a relativelyslow time course over : months, and patients present with an enlarging mass in thechee', orbit, nose, and sinuses. (icroscopically, it is characteri%ed by formation of granulomas, and this differentiates it from chronic invasive fungal sinusitis. spergillus flavus is usually the causative organism. Treatment may involve surgeryin combination with antifungal agents.
CONCLUSION
There are many forms of fungal sinusitis. complete evaluation by your rhinologistwill help to determine if you have a form of fungal sinusitis and how it needs to be
treated, as some forms of fungal sinusitis have distinctly different medical andsurgical treatments.
http://care.american-rhinologic.org/sinus_anatomyhttp://care.american-rhinologic.org/sinus_anatomyhttp://care.american-rhinologic.org/sinus_anatomyhttp://care.american-rhinologic.org/sinus_anatomy
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$"'B"%"N %"D+&+$ %N+SN,S(S -"',%
+leh .
(,(,( S%/&,D-EN$ (0
RS" "r. ?ahidin Sudiro usodo Kota -ojokerto
PEND"H,&,"N
:nfeksi jamur pada hidung sinus paranasal insidennya mulai meningkat
pada dasa$arsa ini pada beberapa penelitian disebutkan 1/I pasien penuh
dengan rinosinusitis jamur memerlukan tindakan bedah baik yang kon%ensional
seperti +ald$ell ;uc ataupun bedah sinus endoskopik fungsional (9S=).
ampir sebagian besar pasien dengan sinusitis kronis terjadi infeksi jamur.
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10 Definisi dan klasifikasi
Rinosinusitis jamur adalah infeksi pada hidung dan sinus paranasal yang
menyebabkan reaksi hipersensitifitas sampai kerusakan jaringan dan destruksi
tulang
*erdapat beberapa macam pembagian rinosinusitis jamur yaitu& 1. akut
(fulminan@in%asif) 2. kronis (indolen@in%asif) 6. misotema !. sinusitis alergi jamur.
Ada yang membagi rinosinusitis jamur menjadi in%asi%e dan non in%asi%e.
Rinosinusitis jamur non in%asi%e terdiri dari mikosis superfisial sinonasal0
misotema ( fungal ball ) dan sinusitis alergi jamur (SA,). Sedangkan yang in%asi%e
terdiri dari sinusitis jamur akut (fulminan) dan sinusitis jamur kronik
(indolen@lambat).
Rinositis jamur non in%asif dapat timbul pada penderita dengan status imun
yang baik jarang menimbulkan in%asi jaringan dan destruksi tulang dalam jangka
$aktu yang cukup panjang.
Rinosinusitis jamur in%asif merupakan infeksi oportunistik yang terjadi pada
penderita immunocompromised seperti penderita A:"S leukimia diabetes
mellitus sedang menjalani radiasi atau kemoterapi.
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gangguan pembauan sefalgi proptopis gangguan penglihatan deficit neurologist
kejang dan gangguan sensoris.
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30 $ambaran radiologi rinosinusitis jamur
,enis pemeriksaan radiologi yang dapat dilakukan untuk melihat kelainan
pada daerah sinus paranasal yaitu &
Foto !olos ke!ala
=oto polos kepala merupakan pemeriksaan a$al kelainan sinus paranasal.
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=o%ea
etmoidalistmoid ant O
post
+ukup jelas
septum
'asi O Sinus
frontal
Sinus
maksila
anya bagian
inferior
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Sinus 'aksila
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sphenoid. -) karena mengurangi
timbulnya artefak logam misalnya tumpatan gigi (amalgam).
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-ukosa sinus paranasal yang normal tipis sehingga kadang F kadang tidak
tampak pada +* scan hanya gambaran tulang dan udara. Apabila terjadi
penebalan mukosa dan jaringan lunak merupakan proses inflamasi yang terjadi
pada sinus disebabkan oleh proses infeksi atau non infeksi fibrosis atau
neoplasma. #ambaran inflamasi pada sinusitis jamur serta airfluid le%el tampak
jelas pada irisan koronal. Sinusitis jamur sering terjadi pada sinus maksila dan
sinus etmoid jarang terjadi pada sinus frontal dan sphenoid. #ambaran +* scan
sinusitis jamur ber%ariasi sesuai pembagiannya in%asi%e atau non in%asi%e.
#( scan rinosinusitis jamur non invasive
Rinosinusitis jamur non in%asif yang tersering gambarannya berupa
aspergilosis pada sinusitis alergi jamur. *ampak bayangan hiperdense pada sinus
yang mengalami infeksi jamur aspergilosis ini disebabkan oleh deposit meineral
berupa kalsium mangan magnesium dan elemen feromagnetik. "idapatkan pula
erosi tulang yang disebabkan remodelling akibat tekanan massa jamur bukan
disebabkan in%asi jamur atau destruksi akibat jamur tampak pada gambar 2.
ampir 2/I penderita sinusitis alergi jamur didapatkan erosi tulang pada
gambaran +* scan sering terjadi pada lamina parirasea sehingga dapat in%asi ke
orbita serta atap etmoid (lamina kibriformis) seperti pada gambar 6 ! dan 7.
#ambar 6& +* koronal erosi lamina papirasea dan lamina kribosa menyebabkan
ektensi intra orbita dan fosa kranii anterior.
#ambar !& +* aksial erosi kli%us oleh sinusitis sfenoetmoid bilateral
menyebabkan ekstensi ke fosa kranii posterior.
#ambar 7& +* aksial erosi dinding posterior sinus frontal.
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-ukosa merupakan jenis sinusitis jamur yang menyerang sinus sphenoid
akibat tumpukan kalsium sulfat kalsium fosfat Dat besi (fe) magnesium dan
mangan maka pada gambaran +* scan tampak bentukan funganl ball atau
gambaran mirip kulit ba$ang (onion sin appearance) yang berupa massa dengan
densitas tulang yang dikelilingi gambaran dengan densitas jaringan mukosa atau
jaringan lunak. Seperti tampak pada gambar .
#( scan rinosinusitis jamur invasive
#ambaran sinusitis jamur in%asi%e pada +* scan mirip keganasan dimana
terjadi destruksi dinding sinus dan jaringan sekitarnya akibat mucormikosis atau
in%asi%e aspergilosis seperti tampak pada gambar 8.
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membedakan massa tumor dengan kelainan akibat sumbatan ostium sinus atau
komplek ostiomeatal.
60 %ingkasan
ntuk menegakkan diagnosis rinodinusitis jamur diperlukan anamnesis yang
cermat pemeriksaan klinis histopatologi@mikologi imunologi@tes alergi dan
pemeriksaan radiology.
Skrining penderita yang dicurigai menderita rinosinusitis jamur masih
memerlukan foto polos kepala dengan beberapa posisi +ald?ell ?aters
submento%erte dan lateral. -engingat fasilitas +* scan dan -R: hanya ada
di kotaF kota besar.
#ambaran aspergilosis pada sinusitis jamur dimana tampak bayangan
hiperdense sedangkan rinosinusitis jamur in%asi%e mirip dengan gambaran
keganasan dengan destruksi dinding sinus dan jaringan sekitarnya sehingga
diperlukan konfirmasi klinis histopatologi@mikologi dan imunologi@tes alergi.
+* scan memeberikan resolusi tulang yang sangat baik disbanding foto
polos dan -R: sehingga diperlukan sebelum dilakukan 9S=.
-R: dapat membedakan jaringan lunak lebih baik dibandingkan +* scan
sehingga diperlukan bila terjadi in%asi jamur ke intracranial.
Daftar !ustaka
1. "hong , ;anDa "+. =ungal rhinosinusitis. :n Kennedy "? 9olger ?
Peinreich S,. "isease of the sinuses& "iagnosis O management. 9+ "ecker :nc
amilton 2//1& 183 F 37.
2.
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!. =ello$s "? Pinreich S,. *he paranasal sinuses O nasal ca%ity. :n& ;ee S Rao
K+ Pimmerman RA eds. +ranial -R: O +* 'e$ Jork& -+#ra$ill 1333&
526 7!.
7. "onald tolaryngology 6 ed. 4ol :::.