Occurrence and Etiology of Fungal Rhino-Sinusitis in a New Delhi Teaching Hospital

Fungal rhinosinusitis is an increasingly important clinical entity with a world-wide distribution. However, there is paucity of information on its occurrence in Delhi and many other parts of India. Aim: The study aimed at probing the occurrence and fungal etiology of rhino-sinusitis in Delhi area. Methods: The study group comprised 50 patients with chronic rhinosinusitis (CRS) examined in the ENT Department, Lady Hardinge Medical College, New Delhi, during July 2006 to September 2007. Endoscopically removed sinus mucosa obtained from patients were investigated for fungal etiology in the Medical Mycology, V. P. Chest Institute, Delhi, by direct microscopy and fungal culture. One half of each specimen was fixed in formal saline for histopathologic examination and the other half processed for mycological investigations. Based on histopathologic observations, the specimens were categorized as follows: Group I comprised specimens showing presence of mucin infiltrated with hyphae suggestive of allergic fungal sinusitis (AFRS); Group II had fungal hyphae without mucin suggestive of fungal ball; Group III had mucin negative for fungal elements suggestive of eosinophilic mucin rhinosinusitis, and Group IV showing neither hyphae nor mucin indicating non-mycotic etiology. Results: Fifty cases of CRS investigated, 23 (46%) had demonstrable fungal etiology. This included 13 cases (26%) classified as AFRS and 10 (20%) as fungal ball. Eight of the cases in AFRS group were confirmed by isolation of fungus in culture. Aspergillus flavus was the etiologic agent in 7 of these cases whereas it was A. fumigatus in a solitary case. In the fungal ball group, 7 cases were diagnosed by demonstration of fungus in histopathologic examination and 3 by direct microscopy of KOH mounts. Only 5 of the fungal ball cases were culture positive, the etiologic agent being A. flavus in 4 cases and an unidentified Aspergillus in a solitary case. Conclusion:Aspergillus flavus is the predominant etiologic agent of fungal rhino-sinusitis in the Union Territory of Delhi. We believe that the disease is being under-diagnosed and under-reported in many parts of India due to inadequate awareness or lack of mycological diagnostic facilities.