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Sinonasal Polyposis and Fungus:A Growing Relationship

Article in INTERNATIONAL JOURNAL OF ENDORSING HEALTH SCIENCE RESEARCH (IJEHSR) · July 2014
DOI: 10.29052/IJEHSR.v2.i1.2014.58-61

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©Advance Educational Institute & Research Centre – 2014 International Journal of Endorsing Health Science Research Print: ISSN 2307-3748
www.aeirc-edu.com Volume 2 Issue 1, June 2014 Online: ISSN 2310-3841

SINONASAL POLYPOSIS AND FUNGUS: A GROWING RELATIONSHIP

Atif Hafeez Siddiqui1, Arsalan Ahmed Sheikh2, Tariq Zahid Khan1, M. Saleem Marfani3 & Arif Ali1
1. Dow University of Health Sciences
2. Liaquat University of Medical & Health Sciences, Jamshoro
3. College of Medicine - Qassim University
Corresponding Author Email: dr.atifhafeez@gmail.com

ABSTRACT
OBJECTIVES: To determine the frequency of underlying fungus in nose and paranasal sinuses in patients present with nasal
polyposis. METHODOLOGY: A total of 324 patients presented with nasal polyps were included in this study. Data collected
from all the patients admitted in ENT department with diagnosis of nasal polyposis. All the relevant information about their
presenting symptoms was recorded in a proforma. Post operatively the removed material was sent for histopathology and
fungal culture. Later the findings of biopsy and culture reports were also recorded and analysed. RESULTS: Out of 324
patients 159 were males and 165 were females. Underlying fungus was present in 226(69.75%) and out of them, 102(45.13%)
were males and 124(54.86%) were females with a P value of 0.039. The mean age was 25.95 ± 9.32 (15-45) years for the
patient with fungus. Aspergillus was the commonest organism found. CONCLUSION: Underlying fungus was found in a
significantly high number of patients presented with nasal polyps and Aspergillus was the commonest organism found.

KEYWORDS
Sinonasal polyps, Fungus, Aspergillus

INTRODUCTION recurrence. The aims of this study were to determine the frequency
of underlying fungus in nose and paranasal sinuses in patients
Nasal Polyps are a common clinical entity. They are basically the present with nasal polyposis.
prolapsed lining of sinus mucosa. The incidence is 1% to 4% of
the total population (Bateman, 2003). The nasal polyps can be the METHODOLOGY
result of chronic rhinosinusitis (Bikhazi, 2004; Hadley, 1997), but
more commonly they are the result of a hypersensitivity response This non-interventional, descriptive study was conducted in the
to an offending antigen. The complex immunological reaction Department of ENT- Head and Neck Surgery, Dow Medical
results in increased edema and inflammation of narrow areas of College and Civil Hospital, Karachi from January 2008 to
mucosal contact such as osteomeatal complex (OMC) causing February 2014. A total of 324 patients were included by non-
obstruction of sinuses (Stammberger, 1997; Mian, 2002; Zacharek, probability, purposive technique. All cases of nasal polyposis of all
2004). This results in stasis of mucin and thus also leads to chronic ages and gender reported for the first time or with recurrence after
rhinosinustis. Further the inhalation and entrapment of fungal treatment, who were immuno-competent and otherwise healthy
spores find an ideal environment their growth (Mian, 2002). The were included in this study. Patients with malignant conditions of
presence of fungus in paranasal sinuses was first reported by nose and paranasal sinuses, immuno-compromised status and
Miller, et al. as allergic aspergillosis of paranasal sinuses in 1981 diabetes were excluded from this study. Data was collected from
(Mian, 2002; Schubert, 2008; Millar, 1982). Since then there has all the patients admitted in this department with diagnosis of nasal
been a worldwide increase in reported cases of fungal infections of polyposis through OPD on basis of clinical examination. Routine
nose and paranasal sinuses. Such fungal infections occur most hematological and biochemical investigations were carried out. CT
commonly in young and otherwise healthy, immuno-competent scan of nose and paranasal sinuses were obtained preoperatively in
individuals (Schubert, 2008; Gupta, 2003). These individuals most every case. Endoscopic sinus surgery was performed in all selected
commonly present with nasal polyps mainly causing nasal cases. The specimen of material removed from nose and paranasal
obstruction and discharge (Mian, 2002). Therefore a high index of sinuses was sent for histopathology and fungal culture. All the
suspicion regarding fungal infection exists in atopic individuals relevant information was recorded in a purposely designed pro
presenting with the diagnosis of nasal polyposis. Polyps when forma. Data analysis was done on SPSS version16.00. Relevant
remain untreated may acquire locally aggressive behaviour which descriptive statistics like frequency and percentage of fungus in
may get further attenuated by the presence of fungus. The polyps cases of nasal polyps were calculated for quantitative variables, sex
may extend intracranially by eroding skull base, while erosion of and presenting symptoms. Mean ± SD (Range) was calculated for
lamina papyracea leads to orbital extension resulting in proptosis, quantitative variable age. Fisher’s exact was used to compare
visual impairment and other ophthalmic symptoms (Marfani, between variable fungus genders wise with level of significance at
2010). Nasal septal deviation, external nasal deformity and facial P≤ 0.05.
asymmetry may also be the consequence. Presence of underlying
fungus in cases of nasal polyposis increases the chances of RESULTS
recurrence (Mian, 2002). Present study highlights this very serious
but often hidden aspect of nasal polyps and also the importance of A total of 324 cases of nasal polyposis were included in this study,
investigating for underlying fungus in such patients, a finding that out of which 159 were males and 165 were female. Underlying
has changed the line of treatment both in terms of surgical options fungus was found in 226(69.75%) subjects. Out of them
and medical therapy to minimize the complications as well as the

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©Advance Educational Institute & Research Centre – 2014 International Journal of Endorsing Health Science Research Print: ISSN 2307-3748
www.aeirc-edu.com Volume 2 Issue 1, June 2014 Online: ISSN 2310-3841

102(45.13%) were males and 124(54.86%) were females (TableNo.1).

Table 1. Characteristics of nasal polyposis Patients (n = 324)

Characteristics n (%)

Age

Mean ±SD Years 25.74±9.64

Gender

Male 159(49.07)

Female 165(50.93)

Fungus

Positive 226(69.75)

Negative 98(30.24)

Nasal Polyp (Laterality)

Unilateral 142(43.8)

Bilateral 182(56.2)

The fungus could not be found in 98(30.24%) subjects, in which 113(50.0%) had unilateral polyposis and a same number of
57(58.2%) were males and 41(41.8%) were females with a patient’s i.e 113(50.00%) patients had bilateral disease. Among 98
significant P-value of 0.039 (Table No.2). 142(43.82%) subjects patients without fungus, 29(29.6%) had unilateral involvement
had unilateral and 182(56.17%) subjects had bilateral disease while in 69(70.4%) patients the polyps were bilateral with a
(Table No.1). Out of 226 patients with underlying fungus, significant P-value of 0.001 (Table No.2).

Table 2. Association of fungus with gender and unilateral and bilateral nasal polyps (n = 324)
Fungus in nasal polyposis patients Fisher's Exact Test
Characteristics Positive Negative P-values
N % n %
Gender 0.039
Male 102 45.1 57 58.2
Female 124 54.9 41 41.8
Nasal Polyp 0.001
Unilateral 113 50.0 29 29.6
Bilateral 113 50.0 69 70.4

DISCUSSION
Out of 324 patients, 263(81.17%) sought medical advice for the
first time regarding the disease while only 61(18.82%) patients had Nasal polyposis has long been considered and treated as a simple
recurrent polyposis. Out of 61 patients with recurrent disease 51 and straight forward pathology but during the recent years it has
(83.60%) patients had fungus. The youngest patient included in been stressed in international literature that this disease deserves a
the study was 9 years old boy and oldest patient was a 50 years old lot of attention. Since the exact etiology of nasal polyposis is still
lady with mean of 25.74 ± 9.64 (9-50) year. The youngest patient debatable and many factors have been attributed for contributing in
with underlying fungus was 15 years old and the oldest patient was their formation and growth, therefore it is important to thoroughly
45 years old with the mean age of 25.95 year and standard investigate the condition because it may be an indicator of some
deviation of ± 9.32 (15-45) years. Aspergillus was the commonest sinister pathology like fungal sinusitis or malignancy. Our study
specie cultured in 166 (73.45%) out of 226 patients who had revolves around the relationship of fungus with nasal polyps.
histopathologically proven fungus. Frequency of fungal involvement in nose and PNS with nasal

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©Advance Educational Institute & Research Centre – 2014 International Journal of Endorsing Health Science Research Print: ISSN 2307-3748
www.aeirc-edu.com Volume 2 Issue 1, June 2014 Online: ISSN 2310-3841

polyps is much commoner then that has been assumed previously. difference in gender distribution regarding presence of polyps in
The freely floating fungal spores in the environment are readily our study was negligible as there were 49.07% males as compared
inhaled by general population. These spores may settle down in the to 50.92% females but a significant “p value” of 0.039 in statistical
sinuses and initiates a hypersensitivity reaction that ultimately analysis of frequency of fungus along with polyps in males and
leads to the formation of polyps in certain individuals. On the females indicates difference in occurrence of fungus among them.
contrary these spores when get access to the nose or PNS of an This finding is contrary to the literature which indicates that sex
individual already having nasal polyps because of any of its wide distribution does not have much value in the course of disease.
spectrum of etiological factors, they find a favourable The diagnosis of presence of fungus is based on histological
environments with local edema, thick inspissant mucin, low pH criterion that has been discussed above. The fungus cultures has
because of decreased ventilation, to flourish and sets a vicious certain limitation and negative fungal culture does not necessarily
circle of inflammatory process. Various studies suggest the major means the absence of fungus as well (Mian, 2002; Schubert, 2004)
role of anterior ethmoid area in pathophysiology of the nasal .Out of 226 histopathologically proven patient with fungus, we
polyposis. Several important anatomical landmarks like uncinate were able to obtain positive culture in 166 (73.45%) patients.
process, ethmoid infundibulum and hiatus semilunaris are Aspergillus as the commonest organism has been mentioned in
associated with anterior ethmoid. They all collectively form a most studies (Mian, 2002; Schubert, 2004; Gupta, 2003; Schubert,
functional unit, termed as ostiomeatal complex (OMC). This 2001; Rupa, 2002; Akthar, 2004; Jain, 2013). A lesser number of
OMC contains ostia of anterior ethmoid, maxillary and frontal positive fungus culture in comparison to histopathological finding
sinuses and considered as the key area in development of polyps can be attributed to the improper handling, storage and transport of
(Zacharek, 2004). Chronic irritation due to any reason in the specimen send for fungal culture. Another possibility is that
narrow areas of ethamoidal air cells causes mucosal edema and histalogically unrecognizable fungal agents might be responsible
subsequently obstruction of natural ostia resulting in impeded for the infection. Recurrence rate is high in nasal polyps even after
mucociliary clearance, bacterial over growth and release of chronic surgical eradication especially if they are accompanied with
inflammatory mediators like cytokines which attract other underlying fungus (Mian, 2002; Schubert, 2004; Schubert, 2000,
inflammatory cells (Zacharek, 2004). The number of mast cells is Kuhn, 2000). Recurrence may be related to the severity of
high within the polyps. Eosinophils play a key role in individual’s atopy, extension of the disease, incomplete surgical
inflammatory process in patients of nasal polyps with underlying eradication or improper postoperative medical therapy. The
fungus. Eosinophil seems to increase production of interlukins allergic fungal polyps often reported to cause bony erosion with
resulting in a vicious circle of inflammatory process (Bikhazi, intra cranial and intra orbital extension (Ghegan, 2006; Al Swiahb,
2004). In this series of 324 patients presented with the diagnosis of 2011). Remaining fungal spores in such difficult approachable
allergic nasal polyps in the Department of ENT and Head and areas might start their reproduction and thus they can set the whole
Neck Surgery, Dow Medical College and Civil Hospital, Karachi, disease process again resulting in recurrence. Although our study
along with search of underlying fungus to find out their frequency does not comprises the rate of recurrence after treatment but at the
in these cases, the different clinical presentations of the disease time of presentation, it was noted that majority of our patient i.e.
were also observed. 263(81.17%) came up with primary presentation and only
61(18.82%) patients had recurrent disease. Out of 61 cases of
In our study we found 226(69.75%) individuals to have myco- recurrent disease, 51(83.60%) patient had under lying fungus.
pathologically and / or histopathologically proven under lying Allergic nasal polyp can be unilateral but mostly they involve
fungus. Typically the microscopic description of the specimens multiple sinuses bilaterally. In our series 142(43.82%) subjects
mostly confirmed multiple polypoidal fragment lined by had unilateral involvements while 182(56.17%) had bilateral
pseudostratified ciliated columnar epithelium. Myxoid underneath disease. The significant “p value“ in this regard indicates the
stroma, with necrotic nonspecific inflammatory exudate variable attitude of the disease process and also that fungus growth
predominantly composed of Eosinophil. Fungal hyphae identified along with polyps was significantly higher in limited disease.
on special stains with the evidence of tissue invasion. This
description exactly matches with the criteria for diagnosing allergic CONCLUSION
fungal sinusitis mentioned in the literature (Mian, 2002; Schubert,
2004; Rupa, 2001; Eloy, 1997). The finding of significantly high The conducted study indicates that the frequency of underlying
percentage (69.75%) of our patients having fungus along with fungus was significantly high in cases of nasal polyposis and
nasal polyps is also strongly supported by the previous studies Aspergillus was the commonest organism identified in these cases.
performed internationally (Mian, 2002; CorRadini, 2003; Schubert, The disease has statistically significant preponderance towards
2001; Rupa, 2001). One of the earliest published study in Pakistani feminine gender. The fungus was found both in cases of unilateral
literature, describing specifically the relationship between nasal and bilateral nasal polyposis without a significant statistical
polyp and fungal sinusitis was conducted in early ninties by Iqbal difference All the subjects were young immunocompetent and
K. et al. (Iqbal, 1993). Only 12 patients of nasal polyposis were otherwise healthy as the mean age was falling in the middle of
included in that study out of which 10(83.33%) patient had third decade of life.
histopathologically proven fungus along with polyps. Another
large series of 200 cases of nasal polyps to find out the aetiological ACKNOWLEDGEMENT
factors surprisingly showed underlying fungus in only 14% of their
patients (Akthar, 2004). Our finding about presence of fungus in Authors are thankful to Raja Fahad Hussain in typing this
young and otherwise healthy individuals is similar to the reports manuscript. We are also grateful to all the senior & junior
appearing in international as well as local literature (Mian, 2002; colleagues for their guidance, support & help in this research work,
Schubert, 2004; Gupta, 2003; Schubert, 2001; Uri, 2003). The

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©Advance Educational Institute & Research Centre – 2014 International Journal of Endorsing Health Science Research Print: ISSN 2307-3748
www.aeirc-edu.com Volume 2 Issue 1, June 2014 Online: ISSN 2310-3841

and also our staff nurses for being extremely helpful in collecting  Kuhn, F. A., & Javer, A. R.(2000). Allergic fungal sinusitis:
and retrieving data from ward record. a four years follow up. Am J Rhinol , 14, 149-156.
 Marfani, M. S., Jawaid, M. A., Shaikh, S. M., & Thaheem, K.
REFERENCES (2010). Allergic fungal rhinosinusitis with skull base and
orbital erosion. J Laryngol Otol ,124(2),161-165.
 Akthar, M. R., Ishaq, N., & Saadatullah, S. (2004). Aetiology  Mian, M. Y., Kamal, S. A., Senthikumaran, G., Abdullah, A.,
of nasal polyp: a study of 200 cases. Pak J Otolyrargyngol , & Pirani, M. (2002). Allergic fungal rhinosinusitis: current
20, 9-11. status. Pak J Otolarygol , 18(3), 36-40.
 Al Swiahb, J. N., & Al Dousary, S. H. (2011). Bone erosion  Millar, J. W., Jhonston, A., & Lamb, D.(1982). Allergic
associated with allergic fungal sinusitis. Saudi Med J, 32(4), aspergillosis of paranasal sinuses. Abstract in the proceedings
417-419. of 143rd meeting of the Pathological society of Great Britain
 Bateman, N., Fahy, C., & Woolford, T. (2003).Nasal Polyps: and Ireland. Journal of Pathology , 137, 56.
still more questions than answers. J Laryngol, 117,1-9.  Rupa, V., Jacob, M., & Matthews, M. S. (2001). Increasing
 Bikhazi, N. B. (2004). Contemporary management of nasal diagnostic yields in allergic fungal sinusitis. J Laryngol Otol ,
poylyps. Otolargyngol Clin N Am, 37, 327-337. 115, 636-638.
 CorRadini, C., Del,N. M., Schiavino, D., Patriarca, G., &  Rupa,V., Jacob, M., Matthews, M. S., Job, A., Kurien, M., &
Paludetti, G. (2003). Allergic fungal sinusitis: a naso-sinusal Chandi, S. M. (2002). Clinicopathological and mycological
specific hyper reactivity for an infectious disease? Acta spectrum of allergic fungal sinusitis in South India. Mycoses,
Otorhinolaryngol Ital, 23(3), 168-174. 45 (9-10), 364-367.
 Eloy, P., Bertrand, B., Rombeaux, P., Delos, M., & Trigaux, J.  Schubert, M. S. (2000). Medical treatment of allergic fungal
P. (1997). Mycotic sinusitis. Acta Otorhinolaryngol Belg , 51, sinusitis. Ann Allergy asthma Immunol , 85, 90-101.
339-352.  Schubert, M. S. (2001). Fungal rhinosinusitis: diagnosis and
 Ghegan, M. D., Lee, F. S., & Scholosser, R. J. (2006). therapy. Curr Allergy Ashtma Rep, 1, 268-276.
Incidence of skull base and orbital erosion in allergic fungal  Schubert, M. S. (2004). Allergic fungal Sinusitis. Otolargyngol
rhinosinusitis. Otolaryngol Head Neck Surg ,134(4), 592-595. Clin N AM, 37 , 301-326.
 Gupta, A. K., Ghosh, S., & Gupta, A. K. (2003). Sinonasal  Stammberger, H. (1997). Examination and endoscopy of the
aspergillosis in immunocompetent Indian children: an eight nose and paranasal sinuses. In N. Mygind,& T. Lindholt(Eds),
year experience. Mycoses, 46, 455-461. Nasal polyposis: an inflammatory disease and its
 Hadley, J. A., & Schaefer,S.D.(1997). Clinical evaluation of treatment(120-136). Copenhagen (Denmark): Munksgaard.
rhinosinusitis: history and physical examination. Otolargngol  Uri, N., Cohen-Kerem, R., Elmalah, I., Doweck, I., &
Head Neck Surg, 117(3), 8-11. Greenberg, E. (2003). Classification of fungal sinusitis in
 Iqbal, K., Saqlain, G., & Jalisi, M. (1993). Nasal Polyposis and immunocompetent patient. Otolaryngol Head Neck Surg
fungal sinusitis. Pak J Otolaryngol , 9, 173-176. ,129(4), 372-378.
 Jain, S., Das, S., Gupta, N., & Malik, J. N. (2013). Frequency  Zacharek, M. A., Peter, N., & Karen, J. F. (2004). The office
of fungal isolation and antifungal susceptibility pattern of the management of recalcitrant rhinosinusitis. Otolaryngol Clin N
fungal isolates from nasal polyps of chronic rhinosinusitis AM , 37,365-379.
patients at a tertiary care centre in North India. Med Mycol ,
51(2), 164-169.

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