Benign Laryngeal and Vocal Fold Lesions
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Benign Laryngeal and Vocal Fold Lesions

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Questions and Answers

What is the mainstay of treatment for vocal granuloma?

  • Serial In-Office Intralesional Steroid Injection
  • Voice therapy exclusively
  • Microsurgery preserving underlying structures (correct)
  • Medical management with PPIs

    • Which granuloma results from the use of intubation during medical procedures?

  • Contact granuloma
  • Hyperfunctioning granuloma
  • Intubation granuloma (correct)
  • Chronic granuloma

    • What potential complication can arise if part of the cyst wall is left behind during surgery?

  • Improved patient reassurance
  • Recurrence of granuloma (correct)
  • Enhanced vocal cord functionality
  • Increased vocal flexibility

    • What management should be avoided in cases of significant voice impairment and suspected malignancy?

    <p>Excising the involved tissue</p> Signup and view all the answers

    What technique minimizes disruption of vocal fold vibratory mechanics during excision of benign lesions?

    <p>Lateral microflap technique</p> Signup and view all the answers

    Which type of benign laryngeal lesion is characterized by bilateral and symmetric swelling?

    <p>Vocal nodules</p> Signup and view all the answers

    Which benign vocal fold lesion is most commonly seen and associated with hoarseness?

    <p>Vocal polyps</p> Signup and view all the answers

    What demographic shows a male preponderance for benign vocal fold lesions?

    <p>School-age children</p> Signup and view all the answers

    What is a common symptom presentation of benign lesions of the vocal folds?

    <p>Throat pain</p> Signup and view all the answers

    Which benign laryngeal lesion arises primarily from the epithelium and lamina propria?

    <p>Vocal nodule</p> Signup and view all the answers

    What is the primary cause of thickening of the basement membrane associated with vocal fold lesions?

    <p>Repeated shearing forces</p> Signup and view all the answers

    Which of the following benign laryngeal lesions is categorized under non-epithelial tumors?

    <p>Lipoma</p> Signup and view all the answers

    Which professional group is more susceptible to benign vocal fold lesions?

    <p>Educators</p> Signup and view all the answers

    What histological finding indicates a potential progression of basement membrane changes?

    <p>Thickening of the basement membrane</p> Signup and view all the answers

    Which of the following is NOT mentioned as part of the medical management for vocal cord issues?

    <p>Oral corticosteroids</p> Signup and view all the answers

    What potential complication can arise from surgical intervention on vocal cords?

    <p>Submucosal scarring</p> Signup and view all the answers

    Which type of vocal cord polyp is characterized by homogenous eosinophilic deposits?

    <p>Telangiectatic polyps</p> Signup and view all the answers

    What is the most common occurrence of vocal cord polyps regarding gender?

    <p>Male predominant</p> Signup and view all the answers

    What is a primary risk factor for the development of vocal cord polyps?

    <p>Overuse or abuse of voice</p> Signup and view all the answers

    Which cellular change is associated with the formation of soft tissue in the superficial lamina propria (SLP) due to phonotrauma?

    <p>Microhaemorrhage and vessel leakage</p> Signup and view all the answers

    What is a primary approach described for voice therapy?

    <p>Modification of lifestyle and vocal behavior</p> Signup and view all the answers

    What is the most common type of polyp found in patients?

    <p>Translucent polyp</p> Signup and view all the answers

    Which clinical feature is associated with vocal polyps?

    <p>Abrupt onset of hoarseness</p> Signup and view all the answers

    What size of vocal polyp typically leads to airway obstruction?

    <p>Large polyp</p> Signup and view all the answers

    What is the primary treatment method for vocal polyps?

    <p>Endolaryngeal microsurgery</p> Signup and view all the answers

    Which type of cyst is lined by squamous epithelium and typically filled with keratin and cholesterol debris?

    <p>Epidermoid cyst</p> Signup and view all the answers

    Which type of vocal cord cyst arises from blocked minor salivary glands?

    <p>Mucus retention cyst</p> Signup and view all the answers

    What is a common appearance of mucus retention cysts?

    <p>Translucent with a yellowish hue</p> Signup and view all the answers

    What can large pedunculated vocal polyps cause when they flip down?

    <p>Improved voice</p> Signup and view all the answers

    What is the primary factor that differentiates the subtypes of fungal sinusitis?

    <p>The degree of invasion of the sinuses</p> Signup and view all the answers

    Which of the following is NOT a subtype of non-invasive fungal sinusitis?

    <p>Chronic invasive rhinosinusitis (CIRS)</p> Signup and view all the answers

    What diagnostic method is essential for a confirmed diagnosis of fungal sinusitis?

    <p>Endoscopic biopsy with histopathology</p> Signup and view all the answers

    Which type of fungal sinusitis is characterized by the presence of an invasion to the sinus structures?

    <p>Granulomatous invasive sinusitis (GIFS)</p> Signup and view all the answers

    Which characteristic is typical of invasive fungal sinusitis compared to non-invasive types?

    <p>It often leads to more severe clinical outcomes.</p> Signup and view all the answers

    Which fungus is most commonly associated with invasive fungal sinusitis in immunocompromised patients?

    <p>Aspergillus</p> Signup and view all the answers

    What is a key histological feature observed in patients with allergic fungal sinusitis (AFS)?

    <p>Charcot-Leyden crystals</p> Signup and view all the answers

    Which type of sinusitis is most commonly asymptomatic and can be challenging to identify?

    <p>Saprophytic fungal sinusitis</p> Signup and view all the answers

    Which organism is most frequently responsible for mucormycosis, a life-threatening infection particularly seen in diabetics?

    <p>Rhizopus</p> Signup and view all the answers

    What complication is most often linked with granulomatous invasive fungal sinusitis in immunocompetent patients?

    <p>Chronic fungal sinusitis</p> Signup and view all the answers

    What is a common method used to differentiate between the subtypes of fungal sinusitis?

    <p>Patient's immune status</p> Signup and view all the answers

    Which of the following is NOT a subtype of invasive fungal sinusitis?

    <p>Allergic fungal rhinosinusitis</p> Signup and view all the answers

    What is an essential method for diagnosing fungal sinusitis?

    <p>Endoscopic biopsy with histopathology</p> Signup and view all the answers

    Which characteristic distinguishes allergic fungal rhinosinusitis from other types of fungal sinusitis?

    <p>Association with specific allergens</p> Signup and view all the answers

    In what context is the secure connection via 'https://' vital when accessing federal government websites?

    <p>To confirm that the site is an official government site</p> Signup and view all the answers

    Which subtype of non-invasive fungal sinusitis typically requires surgical intervention due to obstruction?

    <p>Fungal ball (FB)</p> Signup and view all the answers

    What aspect of patient history is critical in diagnosing fungal sinusitis?

    <p>Exposure to mold or damp environments</p> Signup and view all the answers

    What defines the overarching categories of fungal sinusitis?

    <p>Degree of sinus invasion</p> Signup and view all the answers

    What is the primary prognostic factor for invasive fungal sinusitis?

    <p>Patient's immune status</p> Signup and view all the answers

    Which type of sinusitis is characterized by a potentially life-threatening condition requiring urgent treatment?

    <p>Invasive fungal sinusitis</p> Signup and view all the answers

    What treatment method is considered the mainstay for most forms of fungal sinusitis?

    <p>Surgical debridement</p> Signup and view all the answers

    Which complication can arise from untreated invasive fungal sinusitis?

    <p>Cavernous sinus thrombosis</p> Signup and view all the answers

    What type of sinusitis is predominantly seen in immunocompromised patients, though it can also impact the immunocompetent?

    <p>Fungal sinusitis</p> Signup and view all the answers

    What is a common symptom when both the cavernous sinus and orbital apex are affected?

    <p>Unilateral visual loss</p> Signup and view all the answers

    Which type of sinusitis has a good prognosis when treated timely and effectively?

    <p>Allergic fungal sinusitis</p> Signup and view all the answers

    What is a potential outcome for survivors of invasive fungal sinusitis?

    <p>Chronic pain and facial deformities</p> Signup and view all the answers

    Which intervention is crucial for optimal outcomes in treating fungal sinusitis?

    <p>Interprofessional collaboration</p> Signup and view all the answers

    What underlying health issues might contribute to the recent increase in fungal sinusitis prevalence?

    <p>Increased antibiotic usage</p> Signup and view all the answers

    Which group of patients is primarily affected by invasive fungal sinusitis?

    <p>Immunocompromised patients</p> Signup and view all the answers

    Which type of fungal sinusitis most commonly presents with necrosis of the turbinates?

    <p>Invasive fungal sinusitis</p> Signup and view all the answers

    What is the primary histological finding in allergic fungal sinusitis (AFS)?

    <p>Charcot-Leyden crystals</p> Signup and view all the answers

    Which fungi are most commonly responsible for causing allergic fungal sinusitis?

    <p>Bipolaris and Curvularia</p> Signup and view all the answers

    What is the role of immune fitness in fungal sinusitis development?

    <p>It determines susceptibility to atmospheric fungi.</p> Signup and view all the answers

    Which of the following is a key feature of granulomatous invasive fungal sinusitis (GIFS)?

    <p>Submucosal granulomatous inflammation</p> Signup and view all the answers

    What condition is the most common cause of mucormycosis in developed countries?

    <p>Immune suppression</p> Signup and view all the answers

    What are 'tide lines' in the context of allergic fungal sinusitis diagnosis?

    <p>Characterized rings in histological samples</p> Signup and view all the answers

    Which diagnostic procedure is crucial in confirming fungal rhinosinusitis?

    <p>Functional endoscopic sinus surgery</p> Signup and view all the answers

    What common symptom may indicate sphenoidal fungal sinusitis?

    <p>Vague headache</p> Signup and view all the answers

    Which organism is most frequently associated with cases of mucormycosis?

    <p>Mucor</p> Signup and view all the answers

    Which factor is considered crucial for the classification of fungal sinusitis types?

    <p>Degree of immune response</p> Signup and view all the answers

    Which of the following identifies a characteristic symptom of invasive fungal sinusitis?

    <p>Facial swelling</p> Signup and view all the answers

    What is the typical presentation of patients with mucormycosis?

    <p>Severe necrosis and fatigue</p> Signup and view all the answers

    Which diagnostic method is most sensitive for ruling out invasive fungal sinusitis?

    <p>Polymerase chain reaction (PCR)</p> Signup and view all the answers

    What is the primary benefit of using frozen sectioning during the diagnosis of invasive fungal sinusitis?

    <p>It allows for rapid diagnosis and potential mortality benefit.</p> Signup and view all the answers

    In patients with allergic fungal sinusitis, what is a major criterion that must be present?

    <p>Nasal polyps</p> Signup and view all the answers

    What condition is strongly suggested by 'cheesy and claylike' mucous visualized during intranasal endoscopy?

    <p>Fungus ball</p> Signup and view all the answers

    What is the effect of adding Periodic Acid Schiff (PAS) in the evaluation of necrotic tissue during frozen sectioning?

    <p>It enhances the overall diagnostic accuracy.</p> Signup and view all the answers

    Which organism is typically responsible for mucormycosis, particularly in uncontrolled diabetes?

    <p>Zygomycetes</p> Signup and view all the answers

    Which characteristic is associated with the symptomatology of invasive fungal sinusitis?

    <p>Gradual development of pain, pressure, or fever.</p> Signup and view all the answers

    What is the most common sinus involved in cases of allergic fungal sinusitis?

    <p>Ethmoid sinus</p> Signup and view all the answers

    What does touch preparation (TP) involve in the diagnosis of invasive sinusitis?

    <p>Taking tissue from the margins and plating on a slide.</p> Signup and view all the answers

    Which of the following treatments is typically not recommended for allergic fungal sinusitis (AFS)?

    <p>Topical antifungals</p> Signup and view all the answers

    Which method is recommended for addressing the underlying causes of most cases of invasive fungal sinusitis?

    <p>Management by an infectious disease specialist</p> Signup and view all the answers

    What sign on CT is suggestive of allergic fungal sinusitis?

    <p>Double density sign indicating thick fungal mucin</p> Signup and view all the answers

    What is the treatment of choice for granulomatous sinusitis?

    <p>Surgical debridement</p> Signup and view all the answers

    What does the term 'saprophytic fungal sinusitis' refer to?

    <p>Infections managed with nasal douching.</p> Signup and view all the answers

    What is the most common histological feature seen in chronic invasive fungal rhinosinusitis?

    <p>Dense accumulation of fungal hyphae</p> Signup and view all the answers

    Which treatment is suggested to potentially prevent disease recurrence in chronic invasive fungal rhinosinusitis?

    <p>Long-term antifungal therapy</p> Signup and view all the answers

    Which method has the highest sensitivity for confirming acute invasive fungal rhinosinusitis?

    <p>Mucosal biopsy from middle turbinate</p> Signup and view all the answers

    In the context of chronic invasive fungal rhinosinusitis, which patient condition is most commonly associated with the disease?

    <p>Subtle immune abnormalities</p> Signup and view all the answers

    What is the primary role of triazoles in the management of invasive fungal infections?

    <p>To treat fungal infections that have not responded to standard therapies</p> Signup and view all the answers

    Which type of fungal organism is most frequently implicated in invasive fungal infections, particularly in the sinuses?

    <p>Aspergillus Fumigatus</p> Signup and view all the answers

    Which condition presents with frequent orbital involvement and is similar in clinical appearance to chronic invasive fungal rhinosinusitis?

    <p>Granulomatous invasive fungal rhinosinusitis</p> Signup and view all the answers

    Which feature observed on imaging is most indicative of invasive fungal rhinosinusitis?

    <p>Destruction of sinonasal structures</p> Signup and view all the answers

    What is the typical duration of symptoms in chronic invasive fungal rhinosinusitis?

    <p>More than 12 weeks</p> Signup and view all the answers

    In patients with renal impairment, which treatment option is primarily considered?

    <p>Liposomal amphotericin B</p> Signup and view all the answers

    Which region is noted for having a higher prevalence of granulomatous invasive fungal infections?

    <p>Sudan and surrounding areas</p> Signup and view all the answers

    Which of the following is NOT associated with chronic invasive fungal rhinosinusitis?

    <p>Frequent acute sinus infections</p> Signup and view all the answers

    What key finding is characteristic of the immune system status in patients with chronic invasive fungal rhinosinusitis?

    <p>Subtle abnormalities in the immune system</p> Signup and view all the answers

    What is a significant risk factor contributing to the high mortality rates observed in invasive fungal infections?

    <p>Delayed diagnosis and treatment initiation</p> Signup and view all the answers

    What factor is crucial for improving survival in patients with invasive fungal infections?

    <p>Enhancing the host immune response</p> Signup and view all the answers

    Which fungal species is almost exclusively associated with granulomatous invasive fungal rhinosinusitis?

    <p>Aspergillus flavus</p> Signup and view all the answers

    Which of the following symptoms may prompt a high suspicion of invasive fungal disease in immunosuppressed patients?

    <p>Fever of unknown origin that persists after 48 hours of broad-spectrum antibiotics</p> Signup and view all the answers

    What is the recommended starting dosage range for intravenous amphotericin B in treating invasive fungal infections?

    <p>$0.25 ext{mg/kg/day} to $1.0 ext{mg/kg/day}</p> Signup and view all the answers

    What is a significant limitation of using standard amphotericin B for treatment?

    <p>It is associated with a high incidence of infusion-related reactions.</p> Signup and view all the answers

    What distinguishing characteristic is often seen in the nasal mucosa during early endoscopic examination of patients with invasive fungal disease?

    <p>Discoloration, granulation, and ulceration of the mucosal surfaces</p> Signup and view all the answers

    In which patient demographic is the use of liposomal amphotericin B particularly preferred?

    <p>Immunocompromised patients requiring aggressive antifungal therapy</p> Signup and view all the answers

    What type of alteration in the bone marrow response may affect a patient's ability to overcome invasive fungal disease?

    <p>Enhanced bone marrow reserve leading to higher total white cell count</p> Signup and view all the answers

    Which aspect is critical for the early diagnosis of invasive fungal disease in immunocompromised individuals?

    <p>High index of suspicion based on clinical symptoms despite non-specific lab findings</p> Signup and view all the answers

    What environmental factor may lead to a higher incidence of invasive fungal infections such as mucormycosis?

    <p>Exposure to contaminated soil and decaying organic matter</p> Signup and view all the answers

    What age difference is observed between EMRS and AFRS patients?

    <p>EMRS patients are significantly older than AFRS patients</p> Signup and view all the answers

    Which of the following factors is associated with a higher incidence in EMRS patients compared to AFRS patients?

    <p>IgG1 deficiency</p> Signup and view all the answers

    What distinguishes classic AFRS from EMRS in terms of disease presentation?

    <p>AFRS is characterized by localized IgE-mediated hypersensitivity</p> Signup and view all the answers

    Which of the following is NOT one of the five main clinical characteristics of EMRS patients?

    <p>Allergy to fungi</p> Signup and view all the answers

    Which type of eosinophilia is commonly observed in patients with AFRS?

    <p>Localized eosinophilia</p> Signup and view all the answers

    What kind of disease progression is typically seen in EMRS patients?

    <p>Bilateral disease is usually the norm</p> Signup and view all the answers

    What common feature is observed in both EMRS and AFRS patients?

    <p>Slight male predominance</p> Signup and view all the answers

    What is one characteristic that differentiates the radiographic findings in EMRS from those in AFRS?

    <p>AFRS exhibits more extensive polyp formation</p> Signup and view all the answers

    What is the recommended duration that defines subacute invasive FRS?

    <p>4 to 12 weeks</p> Signup and view all the answers

    What is considered the most common subtype of fungus-related sinusitis?

    <p>Fungus-related eosinophilic FRS</p> Signup and view all the answers

    Which diagnostic process is crucial for distinguishing between different subtypes of FRS?

    <p>Histological examination</p> Signup and view all the answers

    What is a common component of the first-line treatment for invasive FRS?

    <p>Antifungal agents</p> Signup and view all the answers

    How are noninvasive FRS and invasive FRS differentiated in terms of treatment needs?

    <p>Only invasive FRS requires antifungal agents</p> Signup and view all the answers

    In the spectrum of chronic rhinosinusitis (CRS), where does FRS fit?

    <p>An uncommon but significant component</p> Signup and view all the answers

    Which of the following conditions primarily indicates a need for surgical intervention?

    <p>Obstructive invasive fungal sinusitis</p> Signup and view all the answers

    What complication is frequently associated with granulomatous invasive fungal sinusitis?

    <p>Life-threatening fungal infection</p> Signup and view all the answers

    What is the primary active component responsible for the antibacterial property of Manuka honey?

    <p>Methylglyoxal (MGO)</p> Signup and view all the answers

    In the context of allergic fungal rhinosinusitis (AFRS), what was observed in patients who did not undergo surgery prior to receiving antifungal immunotherapy (IT)?

    <p>They did not improve or worsened.</p> Signup and view all the answers

    Which of the following statements regarding the outcomes of patients who underwent surgery before antifungal IT is accurate?

    <p>Patients had varied results with 2 out of 5 showing improvement.</p> Signup and view all the answers

    What is one of the primary roles of glucose in honey for phagocytes?

    <p>It provides essential energy for their function.</p> Signup and view all the answers

    What is a proposed benefit of using hydrogen peroxide in the context of AFRS treatments?

    <p>Acts as a bacteriocidal and anti-inflammatory agent.</p> Signup and view all the answers

    What clinical result was noted after 18 months of antifungal immunotherapy using MGO in patients with Bipolaris?

    <p>Resolution of symptoms and significant improvement in CT scans.</p> Signup and view all the answers

    What is a significant risk factor for developing allergic fungal sinusitis?

    <p>History of asthma or atopy</p> Signup and view all the answers

    Which imaging technique is primarily utilized for diagnosing allergic fungal sinusitis?

    <p>Computed Tomography (CT)</p> Signup and view all the answers

    What is the effect of the acidic environment highlighted in the management of infections?

    <p>Inhibits bacterial growth.</p> Signup and view all the answers

    Which type of bacteria does Manuka honey show efficacy against?

    <p>Both gram-positive and gram-negative bacteria</p> Signup and view all the answers

    What characterizes the immune response in allergic fungal sinusitis?

    <p>Increased IgE-mediated hypersensitivity</p> Signup and view all the answers

    Which clinical feature is typically seen in patients with non-invasive fungal sinusitis?

    <p>Nasal polyps or obstruction</p> Signup and view all the answers

    What is a common finding in histological examination of allergic fungal sinusitis?

    <p>Presence of eosinophils</p> Signup and view all the answers

    Which organism is typically associated with chronic invasive fungal sinusitis?

    <p>Aspergillus species</p> Signup and view all the answers

    What defines the primary treatment approach for allergic fungal sinusitis?

    <p>Surgical debridement and corticosteroids</p> Signup and view all the answers

    What imaging finding is commonly used to differentiate between invasive and non-invasive fungal sinusitis?

    <p>Bony erosion and sinus opacification</p> Signup and view all the answers

    What is the recommended positioning after administering budesonide nasal irrigation in patients?

    <p>In the Mygind position for 2–3 minutes</p> Signup and view all the answers

    What is the concentration of budesonide used in the nasal irrigation for chronic rhinosinusitis (CRS) patients?

    <p>0.5 mg/mL</p> Signup and view all the answers

    What outcome was observed from the use of topical budesonide in post-operative refractory CRS patients?

    <p>Improvements in patient and physician assessments</p> Signup and view all the answers

    Which method of budesonide delivery resulted in improved clinical outcomes without HPA axis suppression?

    <p>Topical nasal irrigation</p> Signup and view all the answers

    What dosage of budesonide is generally administered daily through a turbuhaler for asthmatic patients?

    <p>400 μg</p> Signup and view all the answers

    What type of medication has been explored as an alternative due to the adverse effects of systemic antifungal agents?

    <p>Topical antifungals</p> Signup and view all the answers

    What benefit was shown from the application of budesonide nasal irrigation over a 30-day period?

    <p>Significant improvement in clinical symptoms</p> Signup and view all the answers

    Which characteristic is noted about the evidence regarding topical antifungals for allergic fungal rhinosinusitis (AFRS) patients?

    <p>Scarce and inconclusive</p> Signup and view all the answers

    Study Notes

    Benign Laryngeal Lesions

    • Epithelial Laryngeal Lesions: Include pleomorphic adenoma, oncocytic tumors, squamous epithelium, recurrent respiratory papillomatosis, keratinized papilloma.
    • Non-Epithelial Laryngeal Lesions: Include vascular lesions like hemangioma and lymphangioma, cartilage and bone lesions like chondroma, muscle lesions like leiomyoma and rhabdomyoma, adipose lesions like lipoma, neural lesions like neurilemoma and paraganglioma, and others like fibroma, amyloidosis, laryngeal cysts, and laryngoceles.

    Benign Vocal Fold Lesions

    • Vocal Nodules:
      • Most common in school-age children and adults.
      • More common in males versus females in children and females versus males in adults.
      • Consist of hyperplasia of the epithelial layer, thickening of the basement membrane, and fibrosis in the lamina propria.
      • Treatment includes voice therapy, voice rest, and surgical removal for persistent dysphonia, fibrotic nodules, and suspected malignancy.
    • Vocal Polyps:
      • More common in males versus females.
      • 80% are unilateral and typically located on the edge of the vocal fold.
      • Characterized by abrupt onset of hoarseness often related to vocal misuse.
      • Treatment includes voice therapy, avoidance of irritants, and microsurgical removal.
    • Vocal Cord Cysts:
      • Two types: mucus retention and epidermoid cysts.
      • Mucus retention cysts are linked to salivary gland blockages, often secondary to phonotrauma.
      • Epidermoid cysts are characterized by squamous epithelium and keratin filling.
      • Treatment for both types is microsurgical removal.
    • Vocal Granuloma:
      • Categorized by etiology: intubation, contact, and hyperfunctioning.
      • Result from voice abuse, shouting, chronic cough, and throat clearing.
      • Treatment includes voice therapy, PPI, and serial in-office intralesional steroid injections (SIILSI) for severe impairment.
    • Microflap Technique:
      • Developed by Sataloff and Courey.
      • Utilizes lateral and medial microflap approaches to excise benign vocal cord lesions with minimal disruption of vocal mechanics.

    Misc

    • Most vocal fold lesions require microlaryngoscopic biopsy, except for vocal nodules.
    • Excision of vocal fold lesions requires sparing the anterior commissure, vocal ligament, and posterior commissure.

    Fungal Sinusitis Overview

    • Types: Classified by degree of sinus invasion:
      • Non-invasive: Fungal ball (FB), saprophytic fungal sinusitis (SFS), allergic fungal rhinosinusitis (AFRS)
      • Invasive: Acute invasive rhinosinusitis (AIRS), chronic invasive rhinosinusitis (CIRS), granulomatous invasive sinusitis (GIFS)
    • Diagnosis: Requires multi-faceted approach:
      • Patient history and clinical presentation
      • Imaging (CT scan)
      • Endoscopic biopsy with histopathology
      • Lab work
    • Risk Factors:
      • Immunocompromised: More susceptible to invasive fungal sinusitis, especially those with diabetes, undergoing chemotherapy, or taking corticosteroids.
      • Geographic Location: Some subtypes are more prevalent in certain regions, such as granulomatous invasive sinusitis in India, Sudan, and Pakistan.

    Pathophysiology

    • Causes: Not fully understood, but increasing cases may be due to:
      • Increased use of immune suppressants and antibiotics
      • Growing number of chronic diseases that suppress the immune system
    • Fungal Agents:
      • Molds: More common than yeasts
      • Yeasts: Unicellular organisms
      • Aspergillus: Previously thought to be most frequent cause of AFS and IFS, but recent studies show Bipolaris and Curvularia are more prevalent.
      • Mucor and Rhizopus: Responsible for mucormycosis, characterized by necrosis of the turbinates.

    Clinical Presentation

    • Allergic Fungal Sinusitis (AFS):

      • Most common form
      • Characterized by:
        • Nasal polyps
        • Eosinophilic mucin
        • Positive fungal stain
        • Positive CT findings
      • Symptoms:
        • Congestion
        • Headache
        • Postnasal drip
        • Nasal obstruction

    • Fungal Ball (FB):

      • Often asymptomatic and found incidentally
      • Symptoms, if present:
        • Facial pain
        • Postnasal discharge
        • Nasal crusting

    • Invasive Fungal Sinusitis (IFS):

      • Rare but aggressive, with high mortality rate
      • Characterized by:
        • Invasion of vessels, nerves, and bones
      • Symptoms:
        • Pain, pressure, and fever that progress gradually and then worsen acutely
        • Facial nerve palsies
        • Swelling
        • Diplopia
        • Proptosis
        • Anesthesia
        • Blackened turbinates and nares

    • Granulomatous Invasive Fungal Sinusitis (GIFS):

      • More common outside the US
      • Slow progression
      • Characterized by non-caseating granuloma

    Diagnosis

    • Functional Endoscopic Sinus Surgery:

      • Mainstay of diagnosis and treatment
      • Involves:
        • Observing pathology and anatomy
        • Biopsy of lesions
        • Clearing and washing sinuses
        • Fixing any underlying problems (fistulas, foreign bodies)

    • Histopathology:

      • Examination of tissue samples
      • Confirms diagnosis
      • Identify fungal organisms
      • Identify inflammatory cells
      • Characteristics:
        • AFS: Charcot-Layden crystals, eosinophilic appearing mucin, tide lines, tree rings
        • FB: Entangled mass of fungal organisms in fibrinous, necrotic exudate
        • IFS: Necrotic vascular thrombosis of the mucosa
        • GIFS: Submucosal granulomatous inflammation

    • Imaging: Computed tomography (CT) scan

      • Visualizes:
        • Thickened sinus walls
        • Opacifications
        • Ring-enhancing lesions
        • Bony erosions

    • Additional Diagnostic Tools:

      • Polymerase chain reaction (PCR): Highly sensitive for ruling out fungal sinusitis
      • Frozen sectioning: Rapid method for diagnosing invasive sinusitis, especially useful for mucormycosis
      • Touch preparation (TP): Alternative method for rapid diagnosis, suitable for limited samples or high laboratory workload

    Treatment

    • Surgical Debridement:

      • Preferred treatment for most cases
      • Diagnostic and therapeutic
      • Craniotomy may be necessary for complications

    • Medical Management:

      • Oral corticosteroids: Beneficial for acute and chronic AFS:
        • Suppress inflammation
        • Lower circulating IgE levels
      • Systemic antifungals:
        • Adjunct treatment for invasive fungal rhinosinusitis
        • Amphotericin B: Broad coverage for Mucor and Aspergillus
        • Azole antifungals: May be beneficial
      • Nasal topical steroids:
        • May be used in combination with systemic steroids to reduce recurrence rate
      • Fungal immunotherapy:
        • Alternative treatment for AFS, but costly and short-term benefits may outweigh long-term impacts.
      • Nasal douching: Manages saprophytic fungal sinusitis

    Prognosis

    • Allergic Fungal Sinusitis (AFS):

      • Typically responsive to treatment
      • Recurrence can be controlled
      • Untreated cases can rarely erode adjacent structures

    • Invasive Fungal Sinusitis (IFS):

      • Life-threatening with poor prognosis
      • Invasion can lead to complications:
        • Cavernous sinus thrombosis
        • Central nervous system infections
      • Urgent treatment is required
      • Recurrence is common
      • Survivors may have facial deformities, nerve damage, and chronic pain
      • Prognosis heavily depends on immune status

    • Granulomatous Invasive Fungal Sinusitis (GIFS):

      • Prognosis depends on management of underlying systemic diseases

    Management

    • Interprofessional Collaboration:
      • Internists
      • Infectious disease specialists
      • ENT surgeons
      • Nurses
      • Board-certified infectious disease pharmacists
    • Nursing Role:
      • Patient care before, during, and after procedures
      • Medication administration
      • Monitoring
      • Patient education
    • Pharmacist Role:
      • Recommending antifungals to accompany debridement
      • Verifying steroid dosages

    Complications

    • Cavernous sinus or orbital apex aspergillosis:
      • Rare but potentially fatal
      • Affects cavernous sinus and orbital apex
      • Can cause:
        • Headaches
        • Acute unilateral visual loss
        • Eye pain

    Conclusion

    • Fungal sinusitis is a rare infection but is becoming more prevalent due to factors such as immunodeficiency.
    • Collaborative efforts are crucial for successful diagnosis and treatment.
    • It is essential to differentiate invasive fungal sinusitis from allergic fungal sinusitis as they require different management approaches.
    • Continued research is needed to improve understanding and management of this complex condition.

    Fungal Sinusitis: Overview

    • Fungal sinusitis is categorized based on the degree of sinus invasion: non-invasive and invasive.
    • Non-invasive fungal sinusitis (FS) subtypes:
      • Fungal ball (FB)
      • Saprophytic fungal sinusitis (SFS)
      • Allergic fungal rhinosinusitis (AFRS)
    • Invasive fungal sinusitis (IFS) subtypes:
      • Acute invasive rhinosinusitis (AIRS)
      • Chronic invasive rhinosinusitis (CIRS)
      • Granulomatous invasive sinusitis (GIFS)

    Causes of Fungal Sinusitis

    • The exact etiology of fungal sinusitis is not fully understood.
    • The increasing prevalence could be linked to:
      • Increased use of immunosuppressants and antibiotics.
      • Growth in chronic diseases that suppress the immune system.
      • Exposure to various types of fungi in the air.
      • Predisposing factors: diabetes, chemotherapy, corticosteroids, and immune suppression.
    • Common fungal organisms causing sinusitis:
      • Aspergillus
      • Bipolaris
      • Curvularia
      • Mucor and Rhizopus (mucormycosis)

    Classifications

    • Fungal sinusitis is categorized based on the patient's immune status.
    • Immunocompetent individuals tend to develop non-invasive FS while immunocompromised patients are more susceptible to invasive FS.
    • Invasive fungal sinusitis can be fatal as the infection could spread to the brain, increasing mortality and morbidity.

    Clinical Presentation

    • Allergic fungal rhinosinusitis (AFS):
      • Type 1 hypersensitivity, nasal polyps, eosinophilic mucin presence, positive fungal stain, and positive CT findings.
      • Unilateral disease, asthma, and Charcot-Leyden crystals in mucin.
      • Young patients (20-30) with dark-colored rubbery nasal casts.
      • Ethmoid sinuses are most commonly affected.
      • CT shows a "double density" sign: thick fungal mucin surrounded by hyperplasia.
    • Fungus ball (FB):
      • Common in immunocompetent females, affecting the maxillary sinus.
      • May be asymptomatic and discovered incidentally during CT.
      • Facial pain, postnasal discharge, and nasal crusting may occur.
      • Mucosal injury, such as from sinus surgery or dental work, can contribute.
    • Invasive fungal sinusitis (IFS):
      • Rare but aggressive with a high mortality rate (around 50%).
      • Characterized by invasion of vessels, nerves, and bones.
      • Zygomycetes causing mucormycosis in uncontrolled diabetics is a classic example.
      • Aspergillus infection in AIDS patients or other immunocompromised individuals is another example.
      • Symptoms: pain, pressure, fever, facial nerve palsies, swelling, diplopia, proptosis.
    • Granulomatous invasive fungal sinusitis (GIFS):
      • More prevalent outside the US, particularly in the Middle East and North Africa.
      • Slow-progressing invasive infection characterized by non-caseating granulomas.

    Diagnostic Approaches

    • Functional endoscopic sinus surgery:
      • Mainstay of diagnosis and treatment.
      • Allows for visualization of the pathology, biopsy of lesions, and sinus cleaning.
      • Polypectomy may be performed if indicated.
    • Histopathological analysis:
      • Sample taken from affected tissue (typically middle turbinate).
      • "Cheesy and claylike" mucous suggests fungus ball.
      • Confirmation using histopathology.
    • Polymerase chain reaction (PCR):
      • Highly sensitive method for ruling out the disease.
    • Frozen sectioning:
      • Rapid diagnosis of invasive infection.
      • Frozen tissue is sectioned and stained for microscopic evaluation.
      • PAS staining enhances visualization of necrotic tissue in mucormycosis.
    • Touch preparation (TP):
      • Alternative method for rapid and accurate diagnosis of invasive sinusitis.
      • Tissue samples are plated on a glass slide, stained, and visualized under a microscope.
    • Computed tomography (CT) of the head:
      • Visualizes sinus wall thickening, opacifications, ring-enhancing lesions, and bony erosions.

    Treatment

    • Surgical debridement:
      • Treatment of choice for most cases of fungal sinusitis.
      • Diagnostic and therapeutic.
      • Craniotomy may be required in case of complications.
    • Oral corticosteroids:
      • Beneficial for acute and chronic fungal sinusitis (AFS).
      • Suppress inflammation and lower IgE levels.
      • Prolonged use is discouraged.
    • Systemic antifungals:
      • Adjunct treatment for invasive fungal rhinosinusitis.
      • Amphotericin B is the first drug of choice for invasive fungal sinusitis.
      • Azole antifungals can be beneficial, but concurrent management with an infectious disease specialist is essential.
    • Topical antifungals:
      • Not recommended due to limited success.
    • Fungal immunotherapy:
      • Alternative treatment for AFS.
      • Desensitizes the body to fungal antibodies.
      • Costly with short-term benefits.
      • May reduce the need for corticosteroids.
    • Saprophytic fungal sinusitis:
      • Manageable through nasal douching with saline.
    • Other sinusitis types:
      • Consider bacterial, viral, allergic, and other causes in the differential diagnosis.

    Prognosis

    • Allergic fungal sinusitis (AFS):
      • Typically responsive to surgical treatment.
      • Recurrence can be controlled successfully.
      • Untreated cases may erode into adjacent structures.
    • Invasive fungal sinusitis (IFS):
      • Potentially life-threatening with a poor prognosis.
      • High mortality rate (around 50%) due to complications like cavernous sinus thrombosis and central nervous system infections.
      • Urgent treatment is essential.
      • Recurrence is common, often requiring repeated debridements.
      • Survivors may experience facial deformities, nerve damage, and chronic pain.
    • Granulomatous sinusitis:
      • May be a manifestation of systemic diseases like Wegener granulomatosis.
      • Prognosis depends on the management of the underlying systemic disease.

    Interprofessional Collaboration

    • A multidisciplinary team involving:
      • Internists
      • Infectious disease specialists
      • ENT surgeons
      • Nurses
      • Infectious disease pharmacists
    • Essential for:
      • Accurate diagnosis
      • Timely treatment
      • Patient education
      • Monitoring for complications

    Key Considerations

    • Distinguish invasive fungal sinusitis (requiring urgent treatment) from allergic fungal sinusitis (benign course).
    • Surgical debridement is typically the mainstay of treatment for most types of fungal sinusitis.
    • Consult with a board-certified infectious disease pharmacist for antifungal recommendations and steroid dosing verification.
    • Nurses play a crucial role in patient care, medication administration, monitoring, and counseling before, during, and after procedures.
    • Open communication and prompt reporting of concerns among healthcare professionals are essential for optimal patient outcomes.

    Invasive Fungal Rhinosinusitis (IFRS)

    • IFRS is a serious infection of the sinuses caused by fungi
    • IFRS can be acute, chronic, or granulomatous with different time frames and clinical presentations
    • IFRS commonly involves the ethmoid and sphenoid sinuses

    IFRS Symptoms and Diagnosis

    • Early Symptoms include fever, cough, nasal crusting, epistaxis, headaches, and altered mucosal appearance
    • Late Symptoms include tissue ischemia (white discoloration) and necrosis (black discoloration)
    • Middle turbinate biopsies have high sensitivity (86%) and specificity (100%) in confirming acute invasive FRS
    • CT scans are the primary radiologic investigation for IFRS

    IFRS Treatment

    • Intravenous amphotericin B is recommended for empiric treatment
    • Liposomal amphotericin B is reserved for patients with renal impairment or amphotericin B failure
    • Triazoles (fluconazole, itraconazole, and voriconazole) are effective against most IFRS, but not Mucorales species
    • Granulomatous IFRS, caused by A. flavus, usually occurs in immunocompetent patients, and a cure is elusive
    • Chronic IFRS is a slow, destructive process, mostly in immunocompromised or mildly compromised patients
    • Long-term antifungal treatment (over 1 year) may be required to prevent disease recurrence
    • G-CSF (granulocyte colony-stimulating factor) may improve survival for certain patients

    IFRS Mortality Rate

    • IFRS can have high mortality rates (50-80%) due to intraorbital and intracranial complications

    IFRS Risk Factors

    • Immunocompromised patients are at increased risk for IFRS
    • Diabetes mellitus, chronic corticosteroid use, and AIDS can increase the risk of IFRS
    • ASpergillus fumigatus is a common fungal cause of chronic IFRS

    IFRS Management

    • Aggressive treatment with antifungals and supportive care is crucial
    • Improving the host immune response is critical for survival
    • New therapies like Manuka honey irrigation and anti-IgE therapy show promise

    Allergic Fungal Rhinosinusitis (AFRS)

    • AFRS is a type of chronic rhinosinusitis, which is a chronic inflammation and infection of the sinuses.
    • It is caused by an allergic reaction to mold or fungus.
    • The disease affects the nasal cavity, sinuses, and sometimes the lungs, causing symptoms like nasal congestion, facial pain, and difficulty breathing.
    • It is a distinct subset of patients with chronic rhinosinusitis (CRS).
    • Key characteristics include: Gross production of eosinophilic mucin containing noninvasive fungal hyphae, nasal polyposis, characteristic radiographic findings, immunocompetence, and allergy to fungi.
    • A subgroup of patients do not meet the Bent and Kuhn criteria for diagnosis.
    • There is a significant prevalence of eosinophilia in both the upper and lower airways in patients with AFRS.
    • While bilateral disease is common, 50% of patients have unilateral disease.

    Treatment

    • Surgical removal of fungal debris and allergic mucin has been shown to decrease allergen-specific IgE levels.
    • Topical budesonide delivered via a mucosal atomization device (MAD) has demonstrated improvements in both physician and patient global assessments and a reduction in the use of oral prednisolone.
    • Systemic antifungals can have significant adverse effects, so topical antifungals have been explored extensively.
    • Topical antifungal agents include sprays and lavages.
    • There is a lack of evidence on the effectiveness of topical antifungal sprays or lavage in AFRS patients.
    • Honey has been investigated as a potential treatment for AFRS.
    • Manuka honey, particularly with high concentrations of methylglyoxal (MGO), has shown efficacy against a broad spectrum of gram-positive and gram-negative bacteria.
    • In an in-vitro study, Manuka honey eradicated Methicillin-susceptible Staphylococcus Aureus (MSSA), Methicillin-resistant Staphylococcus Aureus (MRSA), and Pseudomonas Aeruginosa (PA) biofilms.

    Clinical Differences from Eosinophilic Mucosal Rhinosinusitis (EMRS)

    • EMRS is a systemic disease, resulting in bilateral sinusitis.
    • AFRS is a localized IgE-mediated type I hypersensitivity to germinated fungus that can present as either unilateral or bilateral disease.
    • Patients with EMRS have a higher incidence of asthma, aspirin sensitivity, and IgG1 deficiency and a lower incidence of allergic rhinitis compared to AFRS patients.
    • EMRS patients tend to be older than AFRS patients.
    • Both EMRS and AFRS patients have a slight male predominance and demonstrate serum eosinophilia and eosinophilic nasal disease.
    • Budesonide nasal irrigation for 30 days improves clinical symptoms of CRS without HPA suppression.
    • Budesonide nasal spray has not been shown to have significant effects on the hypothalamic-pituitary-adrenal (HPA) axis in asthmatic children and adults.

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    Description

    This quiz explores benign laryngeal and vocal fold lesions, detailing various epithelial and non-epithelial conditions. It covers definitions, prevalence, and treatment options for conditions such as vocal nodules and tumors. Test your knowledge of these important vocal health topics.

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