Eosinophilic fungal rhinosinusitis of the lacrimal sac

Nasolacrimal Duct Obstruction Secondary to Eosinophilic Chronic Rhinosinusitis: A Case Report

A 47-year-old Japanese woman presented with a 1-year history of right-sided epiphora. On initial consultation, the patient had a high right tear meniscus height. CT images revealed bilateral soft tissue opacification in the nasal cavity and maxillary, frontal, and ethmoid sinuses. The lesion in the right nasal cavity and maxillary sinus involved the right lacrimal sac and nasolacrimal duct. Blood test results showed elevated eosinophil count. Endoscopic sinus surgery and excisional biopsy of the nasolacrimal duct were performed. Histopathological examinations of the excised right nasolacrimal duct and nasal polyps from the nasal cavity and maxillary sinus showed high levels of eosinophilic inflammatory infiltrates. The definite diagnosis of eosinophilic chronic rhinosinusitis was made, based on clinical, radiological, and histopathological findings. At 1.5-year follow-up, tear meniscus height was normal, the lacrimal drainage system remained patent, and the rhinosinusitis did not recur.

Two unusual cases of lacrimal sac inflammatory polyps with allergic mucin sine fungi

This case report deals with two patients with lacrimal sac swellings. Case 1 presented with bilateral sac swelling and Case 2 with a unilateral presentation. Dacrocystorhinostomy (DCR) followed by biopsies of both sacs in Case 1 revealed inflammatory polyps of the sac mucosa, identical in appearance to typical nasal allergic inflammatory polyps. The biopsies were accompanied by typical allergic mucin, featuring tiered mucin layers between which were numerous eosinophils, accompanied by Charcot-Leyden crystals. The histology of the dacryocystectomy specimen for Case 2 showed identical histopathological changes with the additional feature of prominent numbers of Immunoglobulin G (IgG)4-positive plasma cells in the stroma of the lacrimal sac inflammatory polyps. These features extend the sites affected by allergic inflammatory polyps and allergic mucin and possible pathogenesis is discussed.

Dacryocystitis As the Initial Presentation of Invasive Fungal Sinusitis in Immunocompromised Children

Sino-orbital fungal infection is a rare, but life-threatening disease seen mainly in immunocompromised patients. While initial clinical impression may vary, dacryocystitis has rarely been described as the initial presenting sign. The authors present 2 pediatric cases of dacryocystitis as the initial sign of invasive fungal sinusitis. To their knowledge, this presenting sign has not been previously reported in the pediatric population. Management strategies and outcomes are discussed.

Entire lacrimal sac within the ethmoid sinus: outcomes of powered endoscopic dacryocystorhinostomy

BACKGROUND

The aim of this study was to report the outcomes of powered endoscopic dacryocystorhinostomy (PEnDCR) in patients with lacrimal sac within the sinus.

MATERIALS AND METHODS

Retrospective analysis was performed on all patients who underwent PEnDCR and were intraoperatively documented to have complete lacrimal sac in sinus. Data collected included demographics, clinical presentations, associated lacrimal and nasal anomalies, intraoperative findings, intraoperative guidance, complications, postoperative ostium behavior, and anatomical and functional success. A minimum follow-up of 6 months postsurgery was considered for final analysis.

RESULTS

A total of 17 eyes of 15 patients underwent PEnDCR using standard protocols, but with additional intraoperative guidance where required and careful maneuvering in the ethmoid sinus. The mean age of the patients was 37.2 (range 17-60) years. Of the unilateral cases, 69% (nine of 13) showed left-side predisposition; 80% of patients showed regurgitation on pressure over the lacrimal sac area. Associated lacrimal and nasal anomalies were observed in 13.3% (two of 15) and 40% (six of 15), respectively. At a mean follow-up of 6.6 months, anatomical and functional success were observed in 93.3% (14 of 15). One patient showed failure secondary to cicatricial closure of the ostium.

CONCLUSION

An entire sac within an ethmoid sinus poses a surgical challenge. Good sinus-surgery training, thorough knowledge of endoscopic anatomy, careful maneuvering, and use of intraoperative navigation guidance result in good outcomes with PEnDCR.

Allergic fungal sinusitis involving the lacrimal sac: a case report and review

BACKGROUNd: We report a case of allergic fungal sinusitis (AFS) involving the lacrimal sac and review the current English literature. A literature search for AFS involving the lacrimal sac revealed two reports with only one of the two cases demonstrating histological evidence of fungal elements. This is just the third such case and only the second reported case with histopathologic confirmation of fungal elements by Gomori methenamine silver (GMS) stain.

MATERIALS AND METHODS

A PubMed database search was performed using combinations of the following key words: allergic fungal sinusitis, lacrimal sac, nasolacrimal duct, ophthalmology, epiphora, orbit. A 70-year-old white man with a history of chronic conjunctivitis and nasal polyps presenting with chronic epiphora was found to have dacryostenosis on the left side. A CT scan of the orbits revealed mucoperiosteal thickening completely obliterating the frontal, ethmoid and sphenoid sinuses.

RESULTS

A left external dacryocystorhinostomy (DCR) was performed and the lacrimal sac contents were studied histopathologically. Microscopic examination of the lacrimal sac contents disclosed allergic mucin with laminated aggregates of eosinophils in various stages of degeneration, Charcot-Leyden crystals and rare noninvasive fungal hyphae confirming the diagnosis of AFS. Fungal elements stained positively with Gomori methenamine silver stain.

CONCLUSION

Although rarely reported, AFS can affect the lacrimal sac. AFS should be suspected in patients with a history of recurrent refractory sinusitis, recurrent dacryocystitis and nasal polyposis. Early diagnosis is important for adequate treatment and prevention of recurrence.

Allergic fungal sinusitis causing nasolacrimal duct obstruction

INTRODUCTION

Allergic fungal sinusitis is thought to represent a chronic autoimmune reaction directed against fungal elements within the sinuses, and is commonly seen in individuals with a history of chronic sinusitis that is refractory to medical therapy. The authors present a case of allergic fungal sinusitis involving the lacrimal drainage system.

CASE

A 54-year-old woman initially presented with recurrent erythema and induration of the left nasolacrimal sac due to dacryocystitis, which was unresponsive to treatment with topical and systemic antibiotics. Radiological evaluation demonstrated the presence of multiple soft tissue masses along the medial canthi. During subsequent endoscopic dacryocystorhinostomy, significant amounts of allergic mucin were found within the sinuses and marked eosinophilia was present within tissue obtained from the lacrimal sac, findings highly suggestive of allergic fungal sinusitis.

CONCLUSION

A diagnosis of allergic fungal sinusitis should be considered in patients presenting with epiphora in the appropriate clinical context. However, involvement of the lacrimal drainage system is an exceedingly unusual presentation.

Complications of allergic fungal sinusitis

PURPOSE

Allergic fungal sinusitis is a syndrome of chronic noninvasive fungal sinusitis that results in the accumulation of eosinophil-rich allergic mucin within the paranasal sinuses. This mucin may become an expansile mass leading to complications that have not been well characterized or classified.

METHODS

Inclusion criteria for this study required meeting previously published diagnostic criteria and complications greater than nasal polyps or sinusitis itself. Four patients from our cohort and 30 patients identified in a literature search formed the study group.

RESULTS

The majority of patients had pre-existing asthma or allergic rhinitis, or both, and 37% had nasal polyps before presentation. However, 27% had no previous history of rhinosinusitis or nasal polyposis. Complications of allergic fungal sinusitis fell into discrete categories: ophthalmic (n=13), sinobronchial allergic mycosis (n=9), bony erosion (n=8), cavernous venous thrombosis (n=3), and otic involvement (n=1).

CONCLUSION

Visual symptoms, proptosis, headaches, and increased nasal symptoms, especially in association with bony erosions on sinus computed tomography, suggest allergic fungal sinusitis and its complications in patients with chronic rhinosinusitis and nasal polyps. Patients with allergic fungal sinusitis may present with a complication of the disease as the first symptom. Complications may be categorized into groups that facilitate surveillance and early identification.

Topical mitomycin C as a postoperative adjunct to endonasal dacryocystorhinostomy in patients with anatomical endonasal variants

PURPOSE

Unusual intranasal conditions may increase the rate of complications and affect success rate of endonasal dacryocystorhinostomy (DCR) surgery. The purpose of this study was to find the influence of endonasal abnormalities on outcome of endonasal DCR surgery and to find the role of topical mitomycin C (MMC) as a postoperative adjunct to endonasal dacryocystorhinostomy in these patients.

METHODS

A total of 23 patients (19 males and 4 females) of bilateral chronic dacryocystitis in the age range of 18-60 years, having endonasal anatomical variants were included in this study. After endonasal DCR, the right side of nasal cavity was packed with 0.05% MMC nasal pack and left side of nasal cavity was packed with normal saline pack for 48 hours. During postoperative visits, the patients were checked for improvement in clinical symptoms and watched for complications including formation of adhesions and/or synechaie. The statistical association between endonasal pathologies and 3 dichotomous outcome variables (clinical features, adhesions, synechaie) was assessed by applying Fisher's Exact Test.

RESULTS

Postoperative retention of nasal packs for 48 hours after endonasal DCR, did not cause any side effect in our patients. An improvement in clinical symptoms (23/23 = 100%) was seen in all the patients on side with 0.05% MMC soaked nasal pack, while 10/23 i.e., 43.47% patients did not show improvement in symptoms on side of saline nasal pack. Postoperatively, the MMC nasal pack side nasal cavity had a healthy nasal mucosa during the entire follow up, while the saline nasal pack side nasal cavity had synechiae in 15/23 (65.2%) patients and adhesions in 15/23 (65.2%) patients. In our study, none of the anatomical endonasal variants had a statistically significant association with either formation of adhesion or formation of synechiae, as the p-value was > 0.05 in all these instances.

CONCLUSIONS

The patients with endonasal anatomical variants have a higher incidence of complications like formation of adhesions and synechaie after endonasal DCR than other patients. Topical MMC is safe and effective agent to decrease the rate of complications when used as an adjunct in endonasal DCR in patients with endonasal anatomical variants.

Mutation of active site residues in the chitin-binding domain ChBDChiA1 from chitinase A1 of Bacillus circulans alters substrate specificity: use of a green fluorescent protein binding assay

A fluorescent binding assay was developed to investigate the effects of mutagenesis on the binding affinity and substrate specificity of the chitin-binding domain of chitinase A1 from Bacillus circulans WL-12. The chitin-binding domain was genetically fused to the N-terminus of a green fluorescent protein, and the polyhistidine-tagged hybrid protein was expressed in Escherichia coli. Residues likely to be involved in the binding site were mutated and their contributions to binding and substrate specificity were evaluated by affinity electrophoresis and depletion assays. The experimental binding isotherms were analyzed by non-linear regression using a modified Langmuir equation. Non-conservative substitution of tryptophan residue (W687) nearly abolished chitin-binding affinity and dramatically lowered chitosan binding while retaining the original level of curdlan binding. Double mutation E668K/P689A had altered specificity for several substrates and also impaired chitin binding significantly. Other substitutions in the binding site altered substrate specificity but had little effect on overall affinity for chitin. Interestingly, mutation T682A led to a higher specificity towards chitinous substrates than the wildtype. Furthermore, the ChBD-GFP hybrid protein was tested for use in diagnostic staining of cell walls of fungi and yeast and for the detection of fungal infections in tissue samples.