Many people who have chronic recurrent sinusitis may have an allergic reaction to fungi rather than a bacterial infection. Treatments for the two are completely different, and in some cases, fungal sinusitis can be life threatening. Two experts and a patient explain.
- Erin Porter, fungal sinusitis patient and founder, EatPrayGetWell.com
- Dr. Donald Dennis, ear, nose & throat surgeon, Atlanta
- Dr. Joseph Han, Professor of Otolaryngology-Head & Neck Surgery, Eastern Virginia Medical School
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16-31 Fungal Sinusitis
Reed Pence: Erin porter of Tampa, Florida, had been having sinus problems since she was in her early 20’s. It took her until she was in her mid 40’s to find out what was wrong.
Erin Porter: I actually had a sinus infection that lasted 25 years and I had four surgeries and I was on, I calculated, over 100 courses of antibiotics in those 25 years. And I had chronic both bacterial and fungal infections. Later I was diagnosed with aspergillus, Aspergillomas is actually what they’re called and they’re fungal balls in the sinuses and I had several. And I would go to an ear, nose, and throat about every two to four weeks in between all these surgeries to get them removed only for them to grow back in the matter of days. So it was an uphill battle, the antibiotics stopped working. I was on even the big guns of antibiotics, the vancomycins, and the tobramycins and it started to become resistant to some. And my future was starting to look pretty bleak.
Pence: Most people think of bacteria when they have sinusitis. Most doctors do, too, at least at first, and antibiotics are the treatment of choice. But if a person’s sinuses are infected with fungi, antibiotics will do nothing and may even make the problem worse.
Donald Dennis: Well it removes the bacteria from the lining and bacteria tend to compete with fungi for food in the environment. So if you remove all the bacteria, then the fungus have free range to grow.
Pence: But Dr. Donald Dennis, an ear, nose and throat surgeon in Atlanta who treated Erin, says that won’t happen to most people. Virtually all of us have fungi in our nose and sinuses, and they don’t affect most people at all.
Dennis: There are people who can be in extreme toxic environments. With fungal lives that will literally kill other people and they don’t get sick.
Joseph Han: That’s the thing that’s kind of amazing, right? So if people have fungus in the nose and you may not have any kind of reaction to it and you may not have any problems. So if you’re not allergic to these certain types of fungus, you don’t have any reaction, there’s nothing that happens.
Pence: Dr. Joseph Han is professor of otolaryngology-head and neck surgery at Eastern Virginia Medical School.
Han: The top layers of the paranasal sinuses have paracells and those push things out and they push it out of the sinuses, they push it back into the back of the throat and you just kind of get rid of it. So you blow it out, or you drain the back of your throat and then it’s gone.
Pence: However, people like Erin who are allergic to fungi may have severe problems that go on and on.
Porter: About 10 percent of the population has a severe susceptibility to mold and there’s about 31 million people in America who have chronic sinusitis. And what they’re finding is those people are the ones that their immune systems just overreact to mold so one person can be fine, working in a building, or one person can be very healthy in the family while the other one is not.
Dennis: People like Erin have an immune issue where they have a genetic dissect in their t-cell which is a white cell that attacks the fungus but in them, they react 9,000 times normal rather than a normal person would just react with .01 percent of their t-cells. Whereas people who have chronic sinusitis react with 3,000 of their t-cells and each one of those 3,000 secretes three inflammatory chemicals so then you have three times 3,000 so that’s where the 9,000 times inflammation comes from per most for so they don’t need many mild force to make them sick.
Pence: Dennis says he believes fungal sinusitis infections are increasing, or at least they’re being diagnosed more often. There’s much more awareness of them these days, especially, according to Han, in the humid south and southeast.
Han: Fungus is ubiquitous, it’s everywhere. But in the south where it’s more humid, it tends to be in the air more commonly. It gets inhaled through the nose and then a few of the sinuses get trapped in the sinus cavity. Now if you take a culture of everyone’s nose, whether they’re healthy or not healthy, almost everyone will have fungus in their nose. But not everybody has an allergic reaction. Only people who have allergies to fungus, what happens is when these fungus get trapped in the sinuses, your body develops an allergic reaction to it. And it recruits cells like eosinophil and it starts to grow. And it grows like a tumor in a sense that you know, once it starts recruiting itself and more of it comes in and it just kind of; it’s a self-perpetuating disease.
Dennis: That immune reaction damages the lining and damages the cilia which are the little hair cells that move the mucus out and makes a small pit in the lining so that the mucus doesn’t drain out. Then they get a secondary bacterial infection. When you just treat that, it tends to recur because the fungus is still there so you’ve got to address the fungus.
Pence: There are a variety of kinds of fungal sinusitis. The allergic form can make life miserable but Han says what are called acute and chronic invasive forms can be life threatening.
Han: For the chronic, it tends to be very slow growing, indolent, usually in patients who can be a little bit immunocompromised, meaning their immune system is not as strong. It’s usually commonly seen among diabetic patients and acute-invasive are definitely patients who are really immunocompromised so these are patients with organ transplants, people who have leukemia and knew they’re going treatment for that. They just have no way of fighting off the fungus. And in these situations, the mortality can be high as 50 percent. They have little symptoms such as a little bit of nasal congestion. And that’s all they have may have but when you look inside their nose, the fungus is basically eating the patient alive. And what it’s doing is invading the blood vessel and causing the crossis to occur. And once that fungus spreads and it spreads along the blood vessels, once it spread into the brain the chance of dying is very, very high.
Pence: Han says it takes a good ear, nose and throat doctor to treat these kinds of infections.
Han: These are emergencies – you see them as soon as you can. You can’t wait two weeks to see them, you try to see them as soon as possible. And when you see these patients, what you do is you take a look inside the nose and one of the first things I look for is whether or not they can feel because when you push an endoscope which is a camera, a long camera, and when you touch the nasal cavities, they should be able to feel it. These patients don’t feel it because the fungus goes into the blood vessels, the blood vessels no longer supply blood to the nerves and the tissues, the nerves die and they can’t feel things and then because the blood supply is now gone, that’s when a tissue becomes necrotic and the only way to diagnose somebody with invasive fungal sinusitis is you have to get a biopsy.
Pence: Fungus may go anywhere in the body… But it generally stays close to the sinuses, in the eye and brain. Han says treatment is extremely difficult.
Han: You have to be very diligent because you have to go in there and try to remove as much of the fungus as possible. You also give them anti-fungal treatment as well. And patients who are immunocompromised try to revert their immunocompromised status. So in patients who have leukemia and are getting chemotherapy to get rid of their leukemia or the blood cell cancers, when you’re trying to use chemotherapy to treat the leukemia, sometimes you’ll have to stop the leukemia so that you can get their cells to fight off these fungus to grow back. Then that’s probably the best prognosis is that the leukocytes which fight off the fungus comes back.
Pence: Yet another form of fungal sinusitis, is not invasive… But Han says mycetomas can sometimes be serious.
Han: Those are things that are relatively benign, other than when it gets really large and starts pressing to the eye or the brain. These fungus kind of grows, the eosinophil is kind of dead and it grows and eventually dies off. And then you have fungus mixed in with dead eosinophils, these dead eosinophils become crystals called Charcot-Leyden crystals. After it grows to a certain size, if it needs to grow more it remodels the bone that pushes into the eye. It pushes into the brain. And you can get what we call proptosis, meaning the eye starts sticking out. You know, medical treatment doesn’t cure these patients.
Pence: Medicines can alleviate pressure and swelling, but Han says only sinus surgery can remove the fungus in those serious cases and begin to stop the cycle. However, treatment doesn’t stop there.
Han: A lot of people think that by doing surgery you can kind of cure the problem, but it hasn’t, because you’re still allergic to fungus and fungus still is in the air. So once it goes to the sinuses, it could grow again. So you got to do sinus regiments plus medical treatment afterwards to prevent the fungus from coming back and the polyps from coming back.
Dennis: The reason they recur is because the immune reaction continues mainly because they’re getting exposure in the environmental air. If you don’t address a fungal load in the air and in the body, you don’t get a long-term result. As it turns out, the air you breathe is five “X” more important to your health than any other treatment.
Pence: That was the case with Erin Porter and her allergic fungal sinusitis. Her initial treatment with another doctor was partially successful.
Porter: He took one look at the CAT scan and said, “You have a severe fungal infection.” I started on the antifungal and I watched my world transform. My sinuses got about 50 percent better. You have to take it out of your sinuses but you also have to address your air. And that’s another thing I wasn’t doing. If people are living in a moldy environment or working maybe in a sick building or a moldy building, it’s gonna come right back.
Pence: Dennis says HEPA-air filtration, getting rid of carpets, and using anti-fungals on laundry help address mold exposure. But how do you know if your chronic sinus infections are fungal in the first place?
Dennis: If they’re having four or five sinus infections a year, they’re treated with antibiotics and they’re recurring or they’re getting it for three or four weeks at a time and having trouble with it resolving and then coming back, those all have chronic sinusitis. It’s bacterial and fungal. The bacteria are the infection that’s apparent and the fungal part is usually more stealth although it can be visible endoscopically in the nose and in a certain number of cases you can actually see the fungus in there. But in a lot of them you don’t see the fungus but you can culture it out.
Pence: One well-known study at the Mayo Clinic found fungal involvement in more than 90 percent of sinus infections. But Han isn’t sure that that’s the complete picture.
Han: If you look at a study, they say like 96 percent of patients with chronic sinusitis have fungus. But if you look at the control, 100 percent of them have it. So both the study group and the control group both have fungus.
Pence: The picture is confusing. That’s why an otolaryngologist or ear, nose and throat specialist is often a good check on recurrent sinus infections that don’t respond to antibiotics.
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I’m Reed Pence.