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One of the most prevalent problems faced by Americans today is their sinuses. Many suffer weeks, months or years with Chronic Recurring Sinusitis (CRS). It may come on as a “sinus attack” stemming from a recent cold and progress to a prolonged suffering of inflammation and pain. Some Americans suffer allergies possibly leading to the cause of sinusitis. It is characterized by symptoms of facial pain, headaches, nasal discharge, post nasal drip, sore throat, swelling, general fatigue, jaw pain, difficulty breathing through the nose as well as a multitude of additional symptoms.

Based on statistics CRS afflicts over 37 million people in the United States. It is estimated that $2 billion are spent each year in the United States on medical care to treat this disease. It is the most common reason people visit their doctor. Doctors visits for this problem range between $100 to $200. Prescription costs very from the treatment prescribed, but are usually over $100. The average American can also expect to miss 4 days of work, adding to the financial impact on the economy as well as the suffers personal finances. Those figures have not been calculated in this repot.

CRS has yet to be completely understood. There are theories only as to what causes it. For many years and today physicians prescribed a treatment of antibiotics (i.e. amoxicillan) in addition to steroids (i.e. prednisone) after diagnosis of a sinus infection or sinusitis. Many people responded to that treatment, but there were many who didn’t. This was an indication that there may be something else other than a bacterial infection present in the sinuses of suffers of CRS. Airborne bacterial contaminants are not alone. There is another competitor to live in your sinuses, fungus. There are thousands of different genera of fungus present in our environment. The sinuses as well as other parts of the body are a perfect environment for them to take root and spawn. Recurrence is common after treatment. “When I take on fungal sinusitis patient, I expect to be married to that patient for the rest of my professional life,” said Frederick Kuhn, MD, director of the Georgia Nasal & Sinus institute in Savannah.

Researchers at the Mayo Clinic set out to do a controlled study of what types fungus are in people’s sinuses. This study had ground breaking results and concluded that there were over 2.7 different genera of fungus present in the sinuses of 202 subjects (96%) out of 210. The control group consisted of 14 individuals who have never had any sinus problems in their medical history. 100% percent of the control group tested positive for fungi in their sinuses. These were overwhelming results that shocked the medical community.

Mayo Clinic published the report in September,1999 in the journal Mayo Clinics Proceedings (Ponikau,J.U., et al. The diagnosis and incidence of allergic fungal sinusitis. Sep;74(9):877-874. This meta-analysis will review the objectives, methods, statistics, results, conclusions and the importance of this study done by the Mayo Clinic. In addition we will take a brief look at the Mayo Clinic. This analysis will also offer information as to how this published studycould be improved. In either it’s supporting information or in the methods used to create the study.

A quick look at the Mayo Clinic. The Mayo Clinic is a charitable, not for profit organization based in Rochester, Minn. It serves as integrated clinical practice, education and research. It is a highly recognized institution and is well known by the medical community as well as the general public. The Mayo Clinic was founded by Dr. William Worrall Mayo and his two sons, William J. and Charles H. Mayo. As business increased several founding doctors joined the practice. By the early 1900’s the Mayo Clinic was seeing over 30,000 people. It was a large group practice that pioneered many improvements in patient care and the administration of health care. The Mayo’s believed in teamwork.

The Mayo’s dissolved their partnership in 1919 and turned the clinics name and assets as well as their life savings over to what is now known as the Mayo Foundation. The staff went to salary and no longer profited from the proceeds of the practice. The Mayo Clinic has seen over 6 million patients, employees 40,000 physicians, scientists, nurses and allied health workers. Today there more than 15,000 alumni practices throughout the United States and the world.

The objectives of this research study in question were to determine what type of fungi were present in the sinuses of a randomly selected group of 210 individuals 14 to sever as a control (although random selection was not stated in the published study). This is not a large group, but results suggested that it did represent a portion of society. What brought this study about was not stated, although it is extremely important for the medical community to recognize the prevalence of this type of infection. It is commonly under diagnosed and often over looked. Physicians routinely prescribe antibiotics for sinusitis. Antibiotics are useless when treating fungal infections, and often are to blame for the invasiveness of fungus. This research will hopefully make physicians consider other treatments such as antifungals and taking cultures to avoid a misdiagnosis, which seems to be common.

One of the difficult areas of this study was to isolate and culture a sample of mucus or polyp. They used a technique that was relatively simple and was quite affective. At this point I would recommend reviewing the study. One of the difficulties in previous studies was not being able to get material to sample for one reason or another. Previous clinicians came up with negative results for this reason. The samples were collected and processed in a reasonable fashion. Preoperative medications such as predinsone prescribed prior to polyps being removed from subjects that under went surgery, this is something that should have been avoided. In addition certain chemicals were used when collecting samples and processing them, how this affected the results is uncertain. There was little mention of what type of people the main subjects were, the only common thread mentioned was the fact that the subjects had CRS. In the control the only common factor was that the group had never had any history of sinus problems.

Judging from what was said in the report it looked as though samples were collected by doctors in their offices, in operating rooms or surgi-centers using a method of collection dictated by the Mayo Clinic. The duration that the sample was exposed to the air should have been stated. The samples that were collected were eventually placed on culture plates at the lab using proper methods to eliminate contamination, which is extremely important when growing a culture. I suggest that a culture plate be exposed to the environment where the specimen being sampled is taken for the same duration that it takes to enclose or cap the specimen in a sealed enclosure. It is common for a non-sterile environment to have fungal spores and other contaminants present. It would have also been wise to indicate where these subjects were located geographically, and state if one genera of fungus was more popular in a particular area of the United States than another.

The main focus of this research study was to identify fungus in the sinuses only. They exposed each subject’s specimens to 5 culture plates each containing various mixtures of agar, antibiotics or antifungals. I would have suggested that they expose each subject’s specimens to a culture plate that did not have any fungicides or antibiotics on it. In order to see what bacteria grew. This could have been easily incorporated into the study and would have had an impact. The design of this study avoided this for one reason or another. With inclusion of bacterial or viral contaminates culture this study would have been a lot more informative and useful.

The findings and statistics were accurate and well defined. The numbers indicated that there was definitely fungus present in the sinuses or the environment where the subjects samples were collected most likely both. The numbers indicated that out of 541 positive cultures over 40 different genera of fungi were represented some newly recognized. Subjects were exposed to skin prick test for allergic reaction to 18 different extracts of fungus, this is where the study lacked inequality. Out of 210 subjects only 179 had the skin-prick test. The results were not accurately published on the skin-prick test as to how many were positive and negative. This is where the report of the study mixed up other factors in the final results. In addition only 95 subjects out of 179 had serum samples taken. These tests performed should have been straight across the board so that each subject has the exact same tests performed making computation simpler and a more accurate representation.

It was interesting that as the study was reviewed they decided to introduce a new term to for what they had discovered. Since the term Allergic Fungal Sinusitis (AFS) was deceptive, that the fungi were causing the subjects problems. They coined a term Eosinophil Fungal Rhinosinusitis due to the fact that eosiniphils were found in the sinuses as well as Charcot-Leyden crystals. The eosiniphils are white blood cells or other granulocytes with cytoplasmic inclusions readily stained by eosin. It is thought that disintegrating eosiniphils create the minute colorless Charcot-Leyden Crystals. These eosiniphils and crystals were found “in high numbers”, as to why? They had a theory, but suggested further study. They were not found in the control group. To summarize what this meant is that the fungus was creating an immune response that was causing a large amount of white cells to form and die in the sinuses forming crystals and other debris. The crystals and accumulation of eosiniphils were actually causing the inflammation that the subjects experienced. This is obviously a big step. Just because fungus was present in the cultures it did not show how much was present in each person and that a majority of the problems that they experience are being caused by what they think is the body immune systems reaction to the presence of fungus. This theory that the immune system response is to blame is partially accurate, yet is only part of the story.

My research indicates that they are on the right track, but are missing key information that I possess. The idea is to understand what it is that the immune system is trying to fight, as well as what is present in the tissue that fungus and other pathogens can grow on. It would be inaccurate to assume that the body is reacting only to allergens such as molds and fungus. Thus represented in the skin-prick test. Although not accurately represented the study stated that less than half of the group had positive tests. Why the allergic reaction or inflammation (I think they confuse the terminology)? There might not be one even happening. This is why they changed the name. It would also be in accurate to assume that the problem is bacterial, which is what has been the norm for 100’s of years. AFS has only been reported in a mere 250 cases. This is where the Mayo study ends. Charcot-Leyden Crystals may hold the key. They are associated with what they think is the degeneration of white cells, but that to is not proven. To find the answers, I think what is needed is to think outside the body and beyond the bodies immune response to foreign substances. Charcot-Layden Crystals may be from something or some where else.

Another interesting point is why wasn’t a previous study as well recognized as this one. It was found in a recent previous study that 60% of the subjects tested were positive for fungus this was not mentioned in the Mayo Study. Although it was not 96% it is still a large number. Something to think about would be if fungus is present in the feet (athletes foot) and is supposedly responsible for dandruff, thrush, and yeast infections why wasn’t it obvious that it would be in the sinuses. Antifungals have been around for many years and they are just finding this out? If I were a a manufacturer of antifungals I would actively being pushing for applications of my product. They use anti fungals sparingly and are not often prescribed. In the case of a vaginal yeast infection they will commonly prescribe only 1 Diflucan (Fluconazole), maybe 2 would prevent the next infection, since fungus is so invasive and recurring. Antifugals are also extremely expensive. Fungus may be systemic in most of the population and I believe this is overlooked intentionally. Fungus may not be totally responsible for all our ailments, but it plays a key role in what is not understood by the medical community.