Materials and Methods
One hundred two patients of target group with clinical features of CAM presenting to the outpatient Department of Otorhinolaryngology were serially recruited and subjected to DNE by an experienced Otorhinolaryngologist, and a tissue sample for KOH mount was sent from representative areas. Informed consent was obtained from all individual participants included in the study and ethical clearance was acquired from the institutional ethical committee.
We excluded cases of invasive fungal sinusitis which were diagnosed elsewhere or presented with recurrence or residual diseases. Nasal endoscopy and biopsy for KOH mount were sent for all 102 patients but CEMRI of paranasal sinuses, orbit & brain could be done in only 60 patients due to financial constraints. Nasal endoscopy was performed in the operation theater using a zero degree rigid endoscope directly and then after decongestion and local anesthesia. Bilateral evaluation was done for all patients to compare both sides. The discoloration, blackening, crusting, or necrotic areas over turbinates, septum, and mucosa were considered as positive findings (Figure 1-e,f). Punch biopsies from the affected tissues were taken. For those with normal DNE, biopsy sample was taken from the middle turbinate of the side the symptoms. The tissue samples were prepared and the KOH mounts were examined for the presence of fungal elements by experienced microbiologists. The morphological findings including broad aseptate hyphae was considered as evidence of the presence of zygomycosis even though invasive fungal sinusitis cannot be diagnosed solely based on the presence of fungal elements on KOH mount. Non-enhancement, thin enhancement, heterogenous enhancement, and enhancement with abnormal findings on CEMRI were considered as positive findings (Figure 2).