Fungal infections of the nose and paranasal sinuses are uncommon compared to bacterial sinusitis. However, its diagnosis remains a clinical challenge due to its diverse presentations and potentially aggressive course. Fungal infections can range from benign colonization to invasive life-threatening conditions especially in immunocompromised patients. With the increasing prevalence of immunosuppressive conditions which includes uncontrolled diabetes mellitus, malignancy, organ transplantation and widespread use of corticosteroids and broad-spectrum antibiotics the incidence of fungal rhinosinusitis has shown a rising trend across the world [1, 2] Fungal rhinosinusitis (FRS) has been broadly classified into non-invasive and invasive types. The non-invasive forms include fungal ball (mycetoma) and allergic fungal rhinosinusitis (AFRS). The invasive types are subdivided into acute invasive chronic invasive and granulomatous invasive FRS. Among these the acute invasive fungal rhinosinusitis is the most fulminant and is commonly caused by fungi of Mucorales and Aspergillus species, these infections require urgent interventions due to their rapid progression and lethal outcomes if left untreated [3]. Clinical presentation of the patients may be nonspecific symptoms such as nasal obstruction, facial pain, nasal discharge, and swelling. However, in invasive cases, especially in immunocompromised cases there could be signs of orbital involvement, cranial nerve palsies, or even intracranial extension. Imaging techniques which include CT and MRI play an important role in diagnosis and also help in delineating the extent of disease. While definite diagnosis relies on histopathological and microbiological examination of tissue specimens [4]. Management of FRS requires a multifaceted approach. Noninvasive forms can be managed by endoscopic and surgical debridement and postoperative follow-up. The invasive fungal sinusitis demands aggressive surgical debridement as well as systematic antifungal therapy and correction of any underlying immunosuppressive state [5].  Amphotericin B is preferred for the treatment of mucormycosis, while voriconazole is preferred for Aspergillus infections. The emergence of the COVID-19 pandemic and associated immunosuppressive treatment regimens, especially corticosteroids, has led to a sudden rise in the incidence of fungal infections during the pandemic [6]. This underscores the importance of timely recognition, early intervention, and standardized management protocols. This current study aimed to evaluate the spectrum, clinical presentation, diagnostic methods, and treatment outcomes of fungal infections of the nose and paranasal sinuses. It also emphasizes the importance of early diagnosis and individualized therapeutic strategies to improve prognosis and reduce morbidity and mortality.

The present prospective study was conducted in the Department of ENT, Rajiv Gandhi Institute of Medical Sciences (RIMS), Adilabad, Telangana in coordination with the Department of Radiology and Microbiology which is a tertiary care teaching Institution. Institutional ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study in vernacular language.

A clinical study was conducted on 30 patients presenting with clinical features suggestive of fungal infections of the nose and paranasal sinuses. The study was carried out in the Department of Otorhinolaryngology. A detailed clinical evaluation was conducted using a predesigned proforma, and informed consent was obtained from all participants.

Clinical evaluation and examination were done for all patients the clinical evaluation included detailed history taking, comprehensive ENT examination, focusing on the nose and paranasal sinuses, and systemic examination (respiratory, cardiovascular, neurological, and abdominal systems) was performed when indicated.

Inclusion Criteria

1. Patients presenting with symptoms suggestive of fungal rhinosinusitis, such as nasal obstruction, facial pain, nasal discharge, headache, or facial swelling.
2. Radiological and endoscopic findings consistent with fungal sinusitis.

Investigations: All patients were evaluated with the following investigations as required. Routine blood tests including complete blood count, blood sugar, and renal function tests. Nasal swab or biopsy for histopathological examination and fungal culture. Diagnostic nasal endoscopy Radiological imaging (CT/MRI of the paranasal sinuses).

Anesthesia and Surgical Protocol: Patients were assessed preoperatively for anesthetic fitness.

The anesthesia protocol was as follows:

• Premedication: Intravenous atropine 0.6 mg, diazepam 0.2 mg/kg, and pentazocine 0.3–0.5 mg/kg.
• Induction: Patients were preoxygenated and induced with 4–5 mg/kg of thiopentone sodium IV until the loss of eyelash reflex. Succinylcholine 1–2 mg/kg IV was administered to facilitate intubation.
• Intubation and Maintenance: Endotracheal intubation was performed using red rubber tubes (sizes 4–5 for children, and 8–9 for adults). Anesthesia was maintained with a 50:50 mixture of nitrous oxide and oxygen along with 0.5–1% halothane. Monitoring included ECG and pulse oximetry.

Surgical Procedure: Nasal endoscopy was performed in all cases using a 0°, 4 mm rigid nasoendoscope (Karl Storz). Surgical management was individualized: 2 patients underwent exenteration with total ethmosphenoidectomy. 28 patients underwent endoscopic sinus clearance using standard nasal instrumentation.

Statistical Analysis: All the available data was refined, segregated, and uploaded to Microsoft Excel. It was analyzed by SPSS version 22 in Windows format. The continuous variables were represented as mean, standard deviation, and percentages, and the categorical variables were calculated by Pearson's chi-square test for p values. The values of p (<0.05) were considered as significant.

A total of 30 patients diagnosed with fungal infections of the nose and paranasal sinuses were included in the study. The age of patients ranged from 20 to 70 years, with a mean age of approximately 45 years. The majority of patients were male (60%), and 40% were female. Table 1 depicts the demographic profile of patients included in the study. Out of 30 patients, 16 (53.3%) were males and 14 (46.7%) were females, indicating a slight male predominance. Age-wise, the highest incidence was observed in the 31–40 years group (33.3%), followed by 41–50 years (23.3%) and 21–30 years (20%). The lowest incidence was seen in the 11–20 years group (6.7%).

Table 2 shows the clinical presentation of the cases of the study. A critical analysis of the table shows that the most frequent clinical manifestation was proptosis seen in 10 patients (33.3%), followed by nasal obstruction with rhinorrhea (20%) and swelling of the nose (16.7%). Visual disturbances such as diplopia and loss of vision occurred in 10% each. Intracranial complications with cranial nerve palsies were seen in 10% of the cases. The combination of orbital symptoms and nasal obstruction emerged as the most common clinical pattern.

Table 3 depicts the fungal agents causing fungal sinusitis in the cases of the study. The predominant fungal etiology was aspergillosis, affecting 12 patients (40%). This was followed by allergic fungal sinusitis in 8 patients (26.7%) and mucormycosis in 6 patients (20%). A less common but notable pathogen was rhinosporidiosis, present in 4 cases (13.3%).

Table 4 reveals the radiological Findings (CT/MRI) done in the cases of the study. Radiological evaluation revealed bone erosion in 10 patients (33.3%), which was the most frequent finding, suggesting invasive fungal disease. Mucosal thickening was observed in 9 patients (30%), and sinus clouding in 8 patients (26.7%). Only 3 patients (10%) had normal or clear imaging studies, indicating that most cases had notable radiological abnormalities.

Table 5 presents the treatment modalities used for the cohort of the study. In terms of medical management, liposomal amphotericin B was used in 15 patients (50%) for 4–8 weeks, primarily in cases of mucormycosis and invasive fungal infections. Steroids were given to 10 patients (33.3%) with allergic fungal sinusitis, and dapsone was used in 4 cases (13.3%) for rhinosporidiosis over 6–12 months. The surgical intervention included maxillary antrostomy in 12 patients (40%), FESS with sphenoethmoidectomy in 10 patients (33.3%), and radical debridement in 3 severe cases (10%). Combined medical and surgical management was the mainstay of treatment.

Fungal infections of the nose and paranasal sinuses have shown an increasing trend recently particularly due to the aging population and increased number of immunocompromised patients. This study was conducted on n=30 patients diagnosed with FNS who reported to our hospital. We evaluated the clinical features, causative organisms, radiological findings, and treatment in these cases. The demographic profile of the cohort revealed that there was male preponderance with 53.3% of cases being males. The commonly involved age group was 31 – 40 years (33.3%). Prateek et al. [7] in a similar study on FNS have shown that males are commonly involved and the third to fifth decade is the population commonly affected possibly due to occupational exposure or lifestyle-related risk factors.

The clinical analysis of signs and symptoms in this cohort revealed proptosis (33.3%) was the common symptom followed by nasal obstruction and rhinorrhea (20%) of cases. Our findings are in concordance with the observations of invasive fungal sinusitis which spread rapidly to involve the orbit and cranial cavity as reported by Ferguson et al. [8] Occurrence of visual symptoms such as diplopia and later loss of vision indicates the aggressive nature of the fungal pathogens this should also serve to alert the treating physician to adopt an aggressive approach. The common etiological agent identified in this cohort was aspergillosis found to be prevalent in 40% of cases, followed by allergic fungal sinusitis (AFS) in 26.7% and mucormycosis in 20% of cases. These observations are similar to those reported by Panda et al. [9] who found aspergillus as the leading cause of both invasive and non-invasive fungal sinusitis in India. Mucormycosis, occurs less commonly however, it is highly invasive fungi and is associated with poor outcomes if treatment is not done promptly. In this study, we found rhinosporidiosis in 13.3% of cases reflecting regional endemicity in certain parts of India which has been previously reported by Job et al. [10] Radiological findings were important adjunct for diagnosis and management of cases. Bone erosion was the most common radiological feature in 33.3% of cases which is because of the invasive nature of the disease. Mucosal thickening and sinus clouding were also commonly observed in our cases. CT and MRI are essential for diagnosis and delineating the extent of disease, especially in cases where there is an orbital or intracranial extension. Shah et al. [11]

The treatment approach in this study was medial and surgical tailored to suit the severity of infection. Liposomal amphotericin B was used in 50% of our cases which is the cornerstone for the management of mucormycosis and invasive aspergillosis due to its broad spectrum of activity. Spellberg et al. [12] steroids were used in patients with allergic fungal sinusitis to control inflammation as supported by current guidelines [13]. Dapsone was administered in rhinosporidiosis, although surgical excision remains the main treatment. The surgical management in most of our cases was done with maxillary antrostomy and FESS with sphenoethmoidectomy. This allowed for effective debridement and radical debridement was reserved for extensive bony-involved cases or those with intracranial extension.

In conclusion, we found fungal sinusitis is a heterogeneous disease and has variable clinical presentation. Early diagnosis using appropriate investigations and the use of antifungal therapy is needed. Timely surgical interventions are required in a few cases for optimal outcomes. Therefore, this study shows that multidisciplinary management of this condition using current guidelines will improve the outcomes in the cases

1. Chakrabarti A, Denning DW, Ferguson BJ, et al. Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Laryngoscope. 2009;119(9):1809–1818.
2. Gillespie MB, O'Malley BW Jr, Francis HW. An algorithmic approach to the diagnosis and management of invasive fungal rhinosinusitis. Am J Rhinol. 2000;14(6):387–392.
3. Turner JH, Soudry E, Nayak JV, Hwang PH. Survival outcomes in acute invasive fungal sinusitis: a systematic review and quantitative synthesis of published evidence. Laryngoscope. 2013;123(5):1112–1118.
4. Ferguson BJ. Definitions of fungal rhinosinusitis. Otolaryngol Clin North Am. 2000;33(2):227–235.
5. Aribandi M, McCoy VA, Bazan C III. Imaging features of invasive and noninvasive fungal sinusitis: a review. Radiographics. 2007;27(5):1283–1296.
6. Sen M, Honavar SG, Bansal R, et al. Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India. Indian J Ophthalmol. 2021;69(7):1670–1692.
7. Prateek S, Banerjee G, Gupta P, Singh M, Goel MM, Verma V. Fungal rhinosinusitis: a prospective study in a university hospital of Uttar Pradesh. Indian J Med Microbiol. 2013;31(3):266–269.
8. Ferguson BJ. Definitions of fungal rhinosinusitis. Otolaryngol Clin North Am. 2000;33(2):227–235.
9. Panda NK, Sharma SC, Chakrabarti A, Mann SB. Paranasal sinus mycoses in north India. Acta Otolaryngol. 1998;118(2):273–277.
10. Job A, Venkateswaran S, Mathan M, Krishnaswami H. Rhinosporidiosis in India: clinical profile and treatment. Laryngoscope. 1993;103(3):313–317.
11. Shah A, Gaur SN, Pawar S, Panjabi C. Allergic bronchopulmonary aspergillosis: a review of 53 cases. Indian J Chest Dis Allied Sci. 2001;43(4):209–215.
12. Spellberg B, Edwards J Jr, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation, and management. Clin Microbiol Rev. 2005;18(3):556–569.
13. Schubert MS. Allergic fungal sinusitis. Otolaryngol Clin North Am. 2004;37(2):301–326.