A NEW CLASSIFICATION AND DIAGNOSTIC-CRITERIA FOR INVASIVE FUNGAL SINUSITIS

Objective: To develop criteria for the diagnosis of invasive fungal si nusitis.Design: Review of the literature on invasive fungal sinusitis in the context of a population of 30 patients with fungal sinusitis an d 24 patients with chronic bacterial sinusitis. Setting: Tertiary care medical center. Results: Our review revealed no consensus in the lite rature on the classification of the syndromes of invasive fungal sinus itis and no criteria for their diagnosis. Moreover, the existing syndr omes of invasive fungal sinusitis lacked specificity and one of the mo re commonly cited syndromes, primary aspergillosis of the paranasal si nuses, is a granulomatous disease that occurs rarely outside Africa. T wo of our 30 patients with fungal sinusitis had a previously unrecogni zed form of invasive disease. Both were middle-aged adults with well-c ontrolled type 2 diabetes mellitus, apical orbital syndrome, and a sim ilar course: proptosis resulting from fungal expansion out of an ethmo id sinus, a protracted illness of 6 months or longer, visual changes, late neurological symptoms reflecting cavernous sinus invasion, and de ath. The syndrome in these 2 patients is distinct from the syndrome of fulminant invasive fungal sinusitis, (eg, mucormycosis) with nasal es char, intracerebral fungal dissemination by vascular invasion, and dea th in days, and the granulomatous form. Conclusions: We conclude that there are 3 forms of invasive fungal sinusitis and propose that they b e termed (1) granulomatous, (2) acute fulminant, and (3) chronic invas ive. The latter category reflects the syndrome seen in our 2 patients. Furthermore, the following 2 diagnostic criteria for invasive fungal sinusitis are proposed: (1) sinusitis confirmed by radiological imagin g and (2) histopathological evidence of hyphal forms within sinus muco sa, submucosa, blood vessels, or bone. The specificity of hyphae withi n sinus mucosa for tissue invasion was supported by the absence of sta inable hyphae in the mucosa of patients with chronic bacterial sinusit is or in the mucosa of our described patients with allergic fungal sin usitis and mycetoma.