الفهرس 
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Abstract
Fungal infections of the sinuses have recently been blamed for causing most cases of chronic rhinosinusitis.. Most fungal sinus infections are noninvasive, except when they occur in individuals who are immunocompromised. Distinguishing invasive disease from noninvasive disease is important because the treatment and prognosis are different for each.
Fungal sinusitis is generally classified into invasive and non invasive fungal sinusitis based on histological features, invasive fungal sinusitis divided into acute, chronic and chronic granulomatous invasive fungal sinusitis. While non invasive fungal sinusitis include saprophytic fungal infestation, fungal ball, and fungus-related eosinophilic (Chakrabarti et al 2009).
Noninvasive fungal rhinosinusitis includes fungal ball („sinus mycetoma‟) and allergic fungal sinusitis (AFS). In fungal ball, multitudes of fungal hyphae are compressed into a thick exudate within a sinus lumen. This may occur in patients with previous sinus surgery, oral-sinus fistula or those without any known predisposing factor. AFS is the other form of noninvasive fungal rhinosinusitis. It represents more of a hypersensitivity response to the presence of extramucosal sinus fungal hyphae, with a prominent element of fungal-specific type I immediate hypersensitivity although the disease appears complex and likely involves the interplay of various inflammatory modalities.
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In contrast to the non-invasive type which usually has a good prognosis, IFS is considered a potentially lethal condition. Moreover, invasive fungal sphenoiditis is more aggressive than invasive fungal infection of the other paranasal sinuses. This is due to the involvement of important surrounding structures such as the orbital apex, cavernous sinus, optic nerve, internal carotid artery, pituitary gland, and cranial nerves. Patients with early stage sphenoid sinus lesions are usually asymptomatic, thus, the diagnosis is often delayed until they are presented to ear, nose and throat specialists. early diagnosis and appropriate treatment are crucial for the improvement of patient survival.
Fungal colonization can occur in Patients with anatomic abnormalities of the paranasal sinuses that impair drainage, such as nasal polyps or chronic inflammatory states, are vulnerable to fungal colonization in these areas. Areas of mucosal injury may cause pooling of mucus and subsequent colonization by fungus. However, these abnormalities are generally of no clinical importance. Aspergillus species are the most common colonizers of the sinuses, but many other species are also reported.
from time to time nasal crusts can become colonized by macroscopic collections of fungi. This saprophytic fungal colonization is most commonly seen in patients with an intact immune system who have had prior sinus surgery. The crust provides a suitable environment for fungal replication and nearby mucosa is usually unaffected. Theoretically, collections
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could grow over time such that they resemble a fungal ball and could begin to impact surrounding mucosa.
No standardized vaccines exist for preventing any of the human infections caused by fungi,
In our study we do a systemic review to Achieve an effective and safe methods in management of different types of fungal sinusitis either by medical or surgical approaches or even combined
Functional endoscopic sinus surgery was the treatment of choice in most of the included studies of fungal ball which was conducted via either middle antrostomy, inferior antrostomy, or a limited approach through the canine fossa for maxillary sinus; and through sphenoidotomy for sphenoid sinus.
In terms of the surgical approaches, the removal of maxillary sinus fungal ball may be long and difficult, in particular when the anterior and/or inferior recesses are involved, as they are notoriously more difficult to manage with the classic endoscopic technique. Therefore, some authors have advocated a combination of the pure endoscopic technique and a complementary endoscopic canine-fossa approach, using a trocar in the canine fossa.
Nevertheless, canine fossa approach may make fungal ball surgery in the long. This leads to an increase in the surgical procedure time, a higher risk of complications due to the difficulty of the technique and, consequently, a higher cost.
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So we can use “gauze technique.” The merits of this technique do not only lie in its simplicity and the high learning curve but also include a higher speed of execution and lower costs than the technique without gauze
The overall effect estimate showed that functional endoscopic sinus surgery led to success rate of 98.1%. While, the recurrence rate was 2.3%.
The studies assessed the efficacy and safety of different modalities for the management of allergic fungal sinusitis.
The success rate of FESS ranged from 92 to 100%.
The use of Post-ESS Steroids significantly reduce postoperative mucosal disease, improve symptoms by endoscopic grading, and reduce inflammatory markers.
The overall effect estimate showed that the recurrence rates after postoperative steroids was 20.6-%.
In addition, one study assessed the efficacy of topical steroid reported a success rate of 100%.
The use of systemic antifungal therapy in patients with AFR has been reported to lead a significant reduction in symptoms, reduction in dependence on oral steroids and prevention of disease recurrence. While possible harms may include renal failure,elevated liver enzymes (most common side effect), rash, headache, malaise, fatigue.
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The overall effect estimate showed that the recurrence rates after postoperative antifungals was 40%. symptoms improvement after postoperative antifungals was 57.7%.
AFRS is defined by a Type 1 hypersensitivity to fungus, so it stands to reason that immunotherapy (IT) could feasibly blunt the immune response to fungus and decrease disease burden. IT potentially reduces mucosal inflammation and the amount of topical/systemic corticosteroids required
The overall effect estimate showed that the recurrence rates after immunotherapy was 9.1%.
In the management of acute invasive fungal sinusitis, Most of the patients were immunecompromised especially who had hematological diseases.
The treatment employed in all studies was a combination of systematic antifungal therapy and aggressive surgical debridement.
The included studies uses a variety of topical and intravenous antifungals including (amphotericin B plus capsofungin and amphotericin B plus voriconazole or amphotericin B alone.
Two studies included patients with chronic invasive infection. Surgical debridement followed by antifungal therapy was performed in all patients.
The overall effect estimate showed that the mortality rates of acute fungal sinusitis was 23.1%