Nose and Paranasal Sinuses: Profile of Fungal Infections

Background: Fungal infections of the nose and paranasal sinuses present with a spectrum of clinical manifestations which is mainly determined by the complex interplay of the pathogenicity of the fungus and the host immune system. In India, most of the fungal infections of the nose and paranasal infections are reported from the southern states although high incidences of paranasal sinusitis are also reported from other states of the country. Data regarding the above from the north-eastern part of the country is hardly available. Hence, it was felt important to make an effort to recognize and detect the presence of fungal infection in this part of the country. Aims & objectives: The present study was conducted to find out the incidence of fungal infections of the nose and PNS among all patients having allergic or infective disorders, to study the various risk factors associated with it, to study the clinical profile of the patients and also to assess the prognosis after treatment. Methods: A prospective study was taken up during the period Feb 2003-Oct 2004 in the Otorhinolaryngology Department of the Regional Institute of Medical Sciences (RIMS), Imphal, Manipur. All the patients attending the OPD and IPD of the department because of chronic allergic and infective disorders were the study subjects. Detailed information on socio-demography and clinical history were collected by using a semi-open interview schedule. Next, a thorough physical examination and examination of the ear, nose and throat were done. Appropriate routine investigations and a thorough fungal study were performed using representative specimens in collaboration with the Department of Microbiology of the same institute. Results: The fungal infection rate was found to be 4.61% (M=4.84% and F=4.21%). This rate went up as high as 17.85% among immuno-compromised patients. The main fungal species identified were Candida (53%) and A. niger (27%). Mucor and Fusarium species were also found. Among the immuno-compromised patients Candida was the commonest species found (93%) whereas among the immune-competent patients A. niger was predominantly found (47%). Nasal obstruction, congested nasal mucosa, epistaxis, nasal discharge and maxillary sinus tenderness were the common clinical findings. Depending on the case-wise merits three-fifths of the cases were given surgical treatment whereas the remaining two-fifths were treated conservatively with medications only. All the cases were either cured or showed improvement. Conclusion: Fungal infection of the nose and PNS in this part of the country was found in 4.61% of patients with chronic allergic and/or infective disorders of the nose and PNS. The common fungi infecting were Candida, A. niger, Mucor and Fusarium. The fungal infection rate was almost six-times increased in immune-compromised patients compared to normal patients. A. niger was predominantly associated with immune-compromised status.

A Microbiological Study of Nasal Packs

Background: Nasal packing is the commonest mode of achieving haemostasis for nasal bleeds. The packs are usually removed after 24 hours but sometimes they have to be kept for two-three days. Out of all the materials used for the purpose, the conventional packing using cotton tape remains the commonest and the easiest. One of the commonest complications of nasal packing is infection. The present study was done to work out the bacterial flora of anterior and posterior nasal packs with different types of antibiotics-soaked packs, duration of pack and type of nasal packing. Further the study aimed to find out the effectiveness of drugs used in nasal packing. Methods: A prospective study was taken up in the Department of Otolaryngorhinology, JNIMS, Imphal, Manipur in which all the patients who attended the OPD or got admitted in the IPD of the otolaryngorhinology department during the period Nov 2012 to Oct 2014 were the study subjects. All nasal packs irrespective of site, disease or duration of usage from these patients were collected with due precaution to avoid contamination during removal. Then the middle part of the pack was cut and collected in sterile bottle under total asepsis. These packs were immediately transported to the Department of Microbiology, JNIMS for full bacteriological examination and sensitivity testing. Results: Out of a total of 120 nasal packs investigated, 98 packs (81.7%) showed bacterial growth. Packs removed after 72 hours showed 100% growth of organisms whereas packs removed within 48-72 hours, within 24-48 hours and packs removed within 24 hours of use respectively showed 92.9%, 59.1% and 76% growth of organisms. Pseudomonas aeruginosa was the most predominant one (41; 34.2%) followed by Staphylococcus aureus (37; 30.8%) and Klebsiella pneumonia (4; 3.3%) in the packs having single infections. Pseudomonas and Klebsiella co-infection was the commonest among packs with mixed infections. Plain gauze and Abgel packs showed 100% growth of micro-organisms which was followed by Betadin (95.6%), Neosporin (94.4%), Soframycin (60.4%). Liquid paraffin-soaked packs did not show any growth. The in-vitro chemo-sensitivity testing showed that almost all the different types of bacteriae isolated were sensitive to Garamycin (85.7%-100%). Cloramphenicol sensitivity was 79% for Pseudomonas, 60% for Staphylococcus and 21% for Klebsiella infection. Other antibiotics gave not so encouraging results especially in Proteus infection. Conclusion: Only a small proportion of nasal packs (18%) remain sterile after use, the chance of culture positivity being higher for posterior nasal packs compared to anterior ones and also depending upon to the duration of use, all packs after 72 hours of use becoming invariably positive. Medication of the packs with antibiotics or antiseptics does not help much in preventing micro-organism growths. Pseudomonas aeruginosa and Staphylococcus aureus are the leading causes of infection. Gentamycin/Garamycin is emerging as the most sensitive antibiotic against the culprit organisms. Drugs which were previously effective against microbes are now only partially sensitive or not effective at all. It is important to caution clinicians and microbiologists to keep a close watch on the sensitivity pattern of the organisms.