Current reviews
Blastomycosis of the head and neck

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Abstract

Background

Blastomyces dermatitidis infection of head and neck structures is a rare clinical entity. However, the potential for significant morbidity warrants clinical consideration and timely diagnosis.

Objective of review

To describe the clinical presentations, diagnostic challenges, and outcomes of otolaryngologic blastomycosis.

Search strategy

A literature search of the Pubmed and Ovid databases with the terms “blastomycosis AND. . . “ followed by all terms related to anatomical regions of the head and neck.

Evaluation method

All publications which discussed pertinent otolaryngologic involvement from blastomycotic infections were evaluated.

Results and conclusion

The larynx was the most commonly reported site of infection, followed by the oral cavity, neck, ear, nasal cavity/paranasal sinuses, and skull base/orbit/calvarium. Diagnosis of blastomycosis was almost universally delayed due to the resemblance of presentation to more common clinical entities, most notably squamous cell carcinoma. A substantial portion of cases (42%) presented without clinical or radiographic evidence of pulmonary infection. The initial diagnostic confusion often resulted in disease progression and trials of invasive therapies. Most patients experienced complete resolution of symptoms and lesions within months of initiation of proper antifungal medications. Permanent sequelae were relatively uncommon and related to the structures involved in the primary infection.

Introduction

Blastomycosis is caused by Blastomyces dermatitidis (B. dermatitidis), a thermally dimorphic fungus that occasionally causes systemic pyogranulomatous disease in humans [1]. Almost all cases of blastomycosis are thought to originate from a pulmonary focus, with secondary seeding via lymphohematagenous spread causing disseminated disease [2]. The most common sites of dissemination are osteoarticular structures, skin, and the genitourinary tract. Blastomycosis in the head and neck region is especially rare and requires a high index of clinical suspicion, especially if patients present with no pulmonary symptomatology.

To the best of our knowledge, there is currently no comprehensive review of blastomycosis with specific attention to involvement of head and neck structures. A literature search was conducted using the Pubmed and Ovid databases with the terms “blastomycosis AND. . . “ followed by all terms related to anatomical regions of the head and neck (e.g. “ear”, “nasal”, “nose”, “sinus”, “oral”, “mouth”, “throat”, “larynx”, “neck,” etc.). The references sections of relevant reports were also evaluated for additional literature sources that were not identified in the MEDLINE search. Forty-nine publications discussed pertinent otolaryngologic involvement, yielding a total of 77 patient cases. This review does not discuss brain infections and isolated cutaneous infections of the face without involvement of other head and neck structures. We review the clinical presentations and diagnostic challenges of blastomycosis pertaining to the practice of otolaryngology.

Section snippets

Larynx

Laryngeal blastomycosis is the most commonly reported presentation of B. dermatitidis involving the head and neck structures with 28 cases documented in the literature [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. Patients almost universally presented with progressive hoarseness of one to several months duration. Presence of cough, sputum production, dysphagia, or dyspnea was variable; hemoptysis was occasionally reported. While pulmonary involvement varied among

Discussion

Blastomycosis is an uncommon entity in the United States, with less than 800 cases annually in one nationwide survey [55]. Blastomycosis in the head and neck region is especially rare and clinical suspicion for this diagnosis is often low, particularly when patients present without pulmonary symptomatology.

In the largest published case series on the subject, Reder and Neel reviewed records from the Mayo Clinic between 1960 and 1990 and found that 23 of the 102 patients with blastomycotic

Conclusion

Blastomycotic infection of the head and neck is a rare clinical entity. Similarity to other disease processes, especially squamous cell carcinoma, often results in initial misdiagnosis. Potentially serious sequelae resulting from this diagnostic delay include disease progression or inappropriate medical and surgical interventions, but initiation of appropriate antifungal agents generally leads to good outcomes.

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