Sinusitis and its management
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39092.679722.BE (Published 15 February 2007) Cite this as: BMJ 2007;334:358
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests