rhinosinusitis jamur

8/18/2019 Rhinosinusitis Jamur

1/34

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


2/34

: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


3/34

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


4/34

(minimal 2 minggu pemberian) dan dilakukan sebelum terapi

pembedahan sinus) serta nasoendoskopi dan siskopi (bila tersedia).

Kriteria rujukan


5/34

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.


6/34

*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


7/34

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.


8/34


9/34

diagnosis. +* scanning of the sinuses re%eals opacification $ith concretions

and@or calcifications.

Sinus mycetoma


10/34

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

http://emedicine.medscape.com/article/1271543-overviewhttp://emedicine.medscape.com/article/1271543-overviewhttp://emedicine.medscape.com/article/1271543-overview


11/34

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.


12/34

#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.


*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


13/34

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


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.



14/34

Follo)*u!


;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.


*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.


*his condition tends to recur. *herefore longterm follo$up care is

recommended.


perience $ith this condition is limited.


15/34

necrosis. +a%ernous sinus thrombosis and in%asion of the +'S are common and

carry a mortality rate of 7/5/I.


: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.


rosion into the adjacent structures (eg orbit +'S) is likely. :nitiate aggressi%e

therapy to a%oid erosion.

+utcome and Prognosis


*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.


*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.


#ood prognosis has been noted in patients $ho recei%e a prolonged course of

systemic antifungals.


16/34

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


17/34

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.


18/34

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


19/34

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.


20/34

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


21/34

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


22/34

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


23/34

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


24/34

$"'B"%"N %"D+&+$ %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.


25/34

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.


26/34

gangguan pembauan sefalgi proptopis gangguan penglihatan deficit neurologist

kejang dan gangguan sensoris.


27/34

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.


28/34

=o%ea

etmoidalistmoid ant O

post

+ukup jelas

septum

'asi O Sinus

frontal

Sinus

maksila

anya bagian

inferior


29/34

Sinus 'aksila


30/34

sphenoid. -) karena mengurangi

timbulnya artefak logam misalnya tumpatan gigi (amalgam).


31/34

-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.


32/34

-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.


33/34

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.


34/34

!. =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 :::.

rhinosinusitis jamur

Documents