Fungal Sinusitis

An article published in the Mayo Clinic Proceedings way back in September, 1999 by the Mayo Clinic suggested that fungal sinusitis may be much more common than previously thought.

The disease is now know as EFRS (eosinophilic fungal rhinosinusitis) or EMRS (eosinophilic mucinous rhinosinusitis); possibly only a major point to a physician. Of greater importance to the patient; those fungal infections may very well have been caused by toxigenic molds.
Fungal growth was found in washings from the sinuses in 96% of patients with chronic sinusitis. Normal controls had almost as much growth, the difference being that those patients with chronic sinusitis had eosinophiles which had become activated. As a result of the activation, the eosinophiles released MBP (Major Basic Protein) into the mucus which attacks and kills the fungus but is very irritating to the lining of the sinuses. It is believed that MBP injures the epithelium and allows the bacteria to proliferate. The injury to the epithelium by the fungus and mucus led to the belief that treatment of chronic sinusitis should be directed at the fungus rather than the bacteria.

Unfortunately the discussion above was not included in the original article by the Mayo clinic. As a result, the article was not well received initially. There was also no information about the success of treatment in the original article, and there was very little discussed about mechanisms. As more data has accumulated, there is more evidence that the problem may be as important as the Mayo Clinic suggests and the significance is starting to be accepted.
The findings of the Mayo Clinic were confirmed in papers presented at The American Rhinologic Society. The well respected group from Graz, Austria were able to show positive fungal cultures in 92 % of their patients. Almost as many of the controls also had fungi. Clusters of eosinophiles were found around fungi in 94% of patients. This is important because we believe that this shows that the eosinophiles are involved in attacking and killing the fungi.

Current techniques make it difficult for private practitioners to clearly establish EFRS. For example, it is possible to tell by electron microscopy that the degranulation of the eosinophile is in response to fungus. The granules will form a horseshoe shape after degranulation, which is specific to activation by fungi. There are also special stains (e.g. chitinase) which the Mayo Clinic has developed which hopefully will be available in the future.

At the present time, some patients are being treated with irrigation with topical antifungals such as Amphotericin B. Many patients require other agents such as nasal or systemic steroids, however many patients were able to stop treatment with steroids. Through current research, we have discovered, patients have an adverse reaction when they have been exposed to toxic molds.

Given topically, Amphotericin B causes minimal problems. These can include burning due to the fact that it must be mixed with sterile water. It cannot be mixed with saline, and must be protected from light and refrigerated. It is therefore very inconvenient to use. We anticipate that patients will need to be treated indefinitely, or at least until we understand better why these problems are occurring.

There is currently a compounded Nizoral Nasal Spray for minor fungal sinusitis and colonization of the sinus cavity, eustachian tubes, and throat. Another remedy that is extremely effective is Nystatin oral powder applied directly to the sinus cavity with a clean swab. It can be mixed with saline as well.
Because irrigation must get into the sinuses in order to be effective, it is often necessary for patients to have endoscopic sinus surgery before irrigation can be effective. It may be possible to use the Grossan irrigator to irrigate effectively without surgery. It is also speculated that since as many as 70% of patients with EFRS have a positive allergy skin test for fungi or mold it may be possible to treat them by standard allergy management. Since we cannot allergy test for all of the fungi, it can be a difficult proposition. We are also concerned about whether exposure to fungi in the environment may also contribute to part of the problem. In some cases, it may be necessary to ascertain what mold levels are in the home.
There are numerous other types of fungal sinusitis which are more customary. The other forms of fungal sinusitis are broken down into several categories: Allergic, Fungul balls (images) (Mycetoma), and Invasive.

Patients who have repeated bouts of sinusitis, as well as those who are immunocompromised should be considered to possibly have a fungal sinusitis. CT scan will sometimes show calcification, but MRI is more sensitive in diagnosis. Cultures are best obtained from the sinuses, as nasal cultures are rather unreliable.
Allergic fungal sinusitis (AFS) is commonly caused by Aspergillus, as well as Fusarium, Curvularia, and others. Patients often have what appears is associated asthma. The criteria include CT or MRI confirmation, a dark green or black material the consistency of peanut butter called "allergic mucin" which typically contain a few hyphae, no invasion, and no predisposing systemic disease. Charcot-Leyden crystals, which are breakdown products of eosinophiles are often found. Sometimes, patients are found to be allergic to the fungus, although this is very controversial. This disease is analogous to Allergic Bronchopulmonary Aspergillosis.
Surgery, irrigation and immunotherapy are helpful, but it can be extremely difficult to treat. It occurs much more commonly in the humid areas in the Southern United States.

Fungus balls often involve the maxillary sinus and may present similarly to other causes of sinusitis including a foul smelling breath. In addition to radiological abnormalities, thick pus or a clay-like substance is found in the sinuses. There is no allergic mucin, but dense hyphae are found. There is an inflammatory response in the mucosa. Removal of the fungus ball is often the typical treatment, but this varies, depending on the circumstances.
Invasive sinusitis can progress rapidly as any infection, and typically necessitates surgery, repeatedly on an emergent basis often requiring AmphotericinB as well. There have been some forms of invasive sinusitis which can cause proptosis. There is a form of chronic invasive fungal sinusitis which is associated with visual abnormalities due to bony erosion.
Fungal sinusitis should obviously be treated by someone with extensive experience in treatment of this disease

Jangan Sepelekan Kanker Nasofaring

Budianto Komari, Kompas
Kanker Nasofaring merupakan kaknekr yang menyerang leher serta kepala dan banyak ditemukan di Indonesia. Tumor itu bisa dikendalikan dengan menerapkan pola hidup sehat dan mendeteksi penyakit itu secara dini.

Bila diagnosis secara dini, terapi akan lebih efektif. Pasien berpeluang sembuh atau mampu bertahan hidup. Selama ini kasus karsinoma atau tumor ganas pada nasofaring didominasi factor ras mongoloid, yaitu penduduk cina selatan dengan angka kejadian 40-50 kasus per 100.000 penduduk, sementara di eropa dan amerika kurang dari 1 kasus per 100.000 penduduk. Di Indonesia, kanker nasofaring menempati peringkat pertama keganasan untuk THT, serta urutam ke-empat terbanyak diantara seluruh jenis keganasan.

Diagnosis secara dini sulit dilakukan karena tumor itu baru menampakkan gejala khas pada stadium lanjut. Apalagi letak tumor itu tersembunyi dibelakang hidung dan pertengahan dasar tengkorak, sehingga sulit dilihat jika tidak diperiksa ahlinya. Gejala awal tidak khas, tidak mirip penyakit lain. Tumor ganas itu umumnya tumbuh dekat sekali dengan muara tuba eustachius (saluran yang terhubung dengan telinga). Sehingga pembesaran sedikit pada tumor menyebabkan tersumbatnya saluran ini. Pembesaran ini menimbulkan gejala antara lain teling berdenging dan gangguan pendengaran satu sisi telinga. Gejala lain adalah pendarahan ringan melalui hidung. Pada stadium lanjut, ditandai pembesaran pada leher.

Bila dideteksi pada stadium awal, angka ketahanan hidup 5 tahun mencapai 76%. Bila pasien diterapi pada stadium tiga dan empat, angka ketahanan hidup 5 tahung mencapai 40%.

Penyebab kanker nasofaring adalah infeksi virus Epstein Barr. Namun ada beberapa faktor lain, yaitu faktor lingkungan seperti iritasi oleh bahan kimia, kebiasaan memasak dengan asap dan kebiasaan mengonsumsi ikan maupun daging yang diawetkan dengan nitrosamine. Lingkungan kerja yang terpapar gas dan bahan kimia industri, peleburan besi, farmaldehida dan serbuk kayu beresiko terserang tumor ganas itu.

Diagnosis karsinoma nasofaring ditegakkan denga biopsi nasofaring. Pemeriksaan penunjang yaitu CT-scan, untuk mendiagnosis tumor-tumor didaerah kepala leher sehingga tumor primer yang tersembunyai bisa ditemukan.

Gangguan pendengaran akibat kemoterapi dengan cisplatin

Sifat farmakokinetik membedakan efek ototoksik cisplatin dan oxalipatin
Medical Update Magazine
Journal of the national cancer institute 2009

Perbedaan sifat farmakokinetik di antara cisplatin dan oxaliplatin dapat menjelaskan perbedaan efek ototoksiknya, karenasecara bermakna lebih banyal cisplatin yang masuk kedalam telinga dalam dibanding oxalipatin.

Dr.Victoria Hellberg dan kawan-kawan dari karolinska institutet Stockholm Swedia melaporkan bahwa ambilan oxiliplatin kokhlear yang lebih rendah disbanding dengancisplatin tampaknya dapat menjelaskan efek ototoksisitas yang lebih rendah.

Untuk dapat mengetahui mengapa kemoterapi dengancisplatin sering menyebabkan gangguan pendengaran sedangkan kemoterapi dengan oxaliplatin yang sama-sama merupakan obat berbasis platinum jarang mempunyai efek sampik ototoksik, maka tim peneliti ini mengukur jumlah cisplatin dan oxaliplatin yang mencapai kokhlea pada marmot.

Para peneliti menemukan bahwa kadar platinum total dalam kokhlea 5 kali lipat lebih tinggi dengan cisplatin disbanding oxaliplatin, setelah pemberian suntikan inravena. Kadar obat perilimfatik secara bermakna juga lebuh tinggi dengancisplatin disbanding oxaliplatin.

Seperti yang sudah diduga sebelumnya, cisplatin pada dosis ekimolar (12.5 mg/kg) menyebabkan efek ototoksik berat pada model binatatng marmot, sedangkan oxaliplatin (16.6 mg/kg) menunjukkan efek ototosik minimal.

Setelah pemberian dosis cisplatin non ototoksik (5 mg/kg) atau oxaliplatin dengan dosis sebanding (16.6 mg/kg), kadar obat perilimfatiknya sama besar. Hal ini menunjukkan kedua obattersebut mempunyai farmakokineyik kokhlear yang berbeda.

Disimpulakan bahwa adanya perbedaan kinetic kokhlear dan ambilan seluler yang ditemukan pada organ pendengaran, sudah cukup untuk menjelaskan perbedaan ototoksisitas diantara cisplatin dan oxaliplatin.

Sinusitis maksilaris kronis

Sinusitis maksilaris kronis menduduki urutan ke-5 dari 10 besar kasus terbanyak di poli THT RSU Dr. Saiful Anwar Malang pada tahun 2006 dengan 918 (6,39%) kasus baru dari 14.349 kasus THT. Sedangkan di poli khusus THT rinologi alergi didapatkan 161 (19,47%) kasus penderita sinusitis maksilaris kronis dari 827 kasus rinologi alergi.


Secara umum, anamnesis dan pemeriksaan fisik harus dilakukan dalam diagnosis rutin sinusitis maksilaris kronik. Pemeriksaan penunjang yang dapat digunakan untuk membantu menegakkan diagnosis sinusitis maksilaris, yaitu transiluminasi, radiologis serta pungsi dan aspirasi.2 Pemeriksaan plain foto radiografi dilakukan untuk melihat keadaan sinus maksilaris, posisi yang terbaik adalah occipitomental (Waters).

Penatalaksanaan sinusitis adalah dengan menggunakan berbagai modalitas terapi, mulai dari terapi konservatif saja sampai irigasi sinus dan pembedahan. Kebanyakan penderita sinusitis dapat diterapi dengan baik menggunakan pendekatan konservatif dengan antibiotika dan dekongestan dan atau dengan tambahan short wave diathermy (SWD) atau low level laser therapy (LLLT).
LLLT dilaporkan mempunyai efek biomodulasi : mengurangi inflamasi, meningkatkan respon imunologis, mengurangi rasa nyeri serta mempercepat penyembuhan luka.4,5 Saat ini LLLT sudah cukup sering digunakan di beberapa rumah sakit, namun terapi dengan SWD untuk sinutitis juga masih digunakan. Pemberian diatermi ini menguntungkan oleh karena tidak invasif terutama untuk anak-anak dan prosedurnya lebih sederhana bila dibandingkan dengan irigasi. Short wave diathermy dikatakan efektif untuk sinusitis kronik karena membantu drainase sinus dengan membuka ostium sinus.