Rus Suheryanto, Rus
Otolaryngology Head&Neck Surgery Department of Medical Faculty Brawijaya University / Dr. Saiful Anwar Regional Public Hospital

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AIRBORNE FUNGI IN CHRONIC RHINOSINUSITIS PATIENTS MAXILLARY SINUS LAVAGE AT DR. SAIFUL ANWAR HOSPITAL MALANG Maharani, Iriana; Suheryanto, Rus; Retnoningsih, Endang
BALI MEDICAL JOURNAL Vol 5 No 2 (2016)
Publisher : BALI MEDICAL JOURNAL

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Abstract

Background: Chronic rhinosinusitis has a significant impact on the quality of life and health of adult population. Role of airborne fungi remains a controversy and have become the source of discussion for decades. Objective to know the prevalence of airborne fungi in the chronic rhinosinusitis with or without polyps patients and to know the possible effect of airborne fungi on chronic rhinosinusitis inflammation. Methods: This is a cross sectional research in the Saiful Anwar Public Hospital Malang, there were 29 patients involved. We examine fungi culture, H&E staining and DNA fungi by using PCR from sinus lavage sample. From the blood serum we examine allergen specific IgE, IgG3, IL-13 and IL-5. Results: Fungi culture there were 31,03 % of sample growth but only matches the PCR result in 3 samples (10,34 %). From PCR examinations we found all sample were positive with 2-5 species fungi, Alternaria alternata was found positive in 24,13% samples. There was an increment of IgE allergen specific and IL-5, a decrement of IL-13 and IgG3 in all of our samples regardless presence of nasal polyps and species of fungi found in PCR. Conclusions: PCR is a more reliable method compare to fungal culture. The presence of fungi in all of our samples could indicate fungi contribution to the disease pathophysiology. The increased level of Il-5 was not followed by IL-13; it may happen through PRR pathway.
Pengaruh vitamin D3 terhadap kadar vitamin D (25(OH)D) dan sel T Regulator pada rinitis alergi Handoko, Rizki Ekaputra; Suheryanto, Rus; Murdiyo, Muhammad Dwijo
Oto Rhino Laryngologica Indonesiana Vol 47, No 2 (2017): Volume 47, No. 2 July - December 2017
Publisher : PERHATI-KL

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (669.55 KB) | DOI: 10.32637/orli.v47i2.223

Abstract

Latar belakang: Rinitis alergi (RA) adalah peradangan atau inflamasi pada mukosa atau selaput lendir hidung yang didasari oleh reaksi hipersensitivitas tipe 1 dan diperantarai IgE. Rinitis alergi merupakan tipe rinitis kronis yang sering dijumpai. Sebanyak 30-50% penderita rinitis memiliki pemicu alergi dan prevalensinya cenderung meningkat. Vitamin D mempunyai peran memodulasi respon imun alamiah dan adaptif. Banyaknya pengaruh vitamin D dalam sistem imun diharapkan dapat mengatur aktivitas berbagai sel kekebalan, serta fungsi kekebalan tubuh dari epitel sel pada RA, namun konsensus sebagai bagian terapi RA saat ini masih belum ada. Tujuan: Mengetahui pengaruh pemberian vitamin D3 terhadap kadar vitamin D (25(OH)D) dan sel T Regulator (T reg) pada rinitis alergi. Metode: Penelitian eksperimental murni dengan rancangan penelitian randomized clinical trial (RCT) double blind, pre and post test control group dengan perlakuan berupa pemberian terapi sesuai ARIA (Allergic Rhinitis and its Impact on Asthma) dan vitamin D3 oral diberikan selama 4 minggu. Dilakukan penilaian VAS (Visual Analogue Scale), TNSS (Total Nasal Symptom Score), serta kadar vitamin D darah dan persentase sel T reg pada awal dan 4 minggu setelah perlakuan. Hasil: Pada kelompok perlakuan terdapat perbedaan bermakna kadar vitamin D sebelum dan sesudah perlakuan (p=0,01). Terdapat perbedaan yang bermakna dari peningkatan persentase sel T reg pada kelompok perlakuan dibandingkan kelompok kontrol (p=0,02). Terdapat hubungan antara peningkatan persentase sel T reg dengan kadar vitamin D pada kelompok perlakuan (p=0,01). Kesimpulan: Vitamin D3 dapat meningkatkan kadar vitamin D dan persentase sel T reg secara bermakna pada pasien rinitis alergi persisten sedang berat. Kata kunci: Rinitis alergi, vitamin D, sel T regulator ABSTRACT Background: Allergic rhinitis (AR) is an inflammatory disease of nasal mucosa based on type 1 hypersensitivity reaction and mediated by IgE. Allergic rhinitis is the most common type of chronic rhinitis. About 30±50% of patients with allergic rhinitis have trigger factors and its prevalence is increasing. Vitamin D has a function in modulation of innate and adaptive responses. The role of vitamin D in immune system is expected to regulate various immune cells activity, and the immune function of AR epithelial cells, but there were no consensus yet about vitamin D as part of AR therapy. Objective: To identify the effect of vitamin D3 on level of vitamin D (25(OH)D) and T regulator (T reg) cells in allergic rhinitis patients. Methods: This study was purely experimental research with randomized clinical trial, double-blind, pre and post test control group treated with appropriate therapy according to ARIA (Allergic Rhinitis and its Impact on Asthma) and vitamin D3 given orally for 4 weeks. Evaluations of VAS (Visual Analogue Scale) and TNSS (Total Nasal Symptom Score) value, vitamin D levels and the percentage of T reg cells were carried out at baseline and 4 weeks after treatment. Results: In the treatment group there was a significant difference between vitamin D levels before and after treatment (p=0.01). There was a significant difference on increased percentage of T reg cells in the treatment group compared with the control group (p=0.02). There was a correlation between the increasing percentage of T reg cells with vitamin D levels in the treatment group (p=0.01). Conclusion: Vitamin D supplementation could increase the level of vitamin D and the percentage of T reg cells significantly in patients with severe persistent allergic rhinitis. Keywords: Allergic rhinitis, vitamin D, T regulatory cell
Mometasone furoate topikal menurunkan kadar IL3, IL9-serum dan jumlah eosinofil mukosa hidung penderita rinitis alergi Kurniawan, Agus; Linggawan, Stephani; Retnoningsih, Endang; Suheryanto, Rus; Handoko, Edi; Soehartono, Soehartono
Oto Rhino Laryngologica Indonesiana Vol 43, No 2 (2013): Volume 43, No. 2 July - December 2013
Publisher : PERHATI-KL

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (92.585 KB) | DOI: 10.32637/orli.v43i2.70

Abstract

Latar belakang: Rinitis alergi merupakan inflamasi kronis mukosa hidung yang diperantarai oleh IgE, sering berhubungan dengan banyak ko-morbid dan berdampak pada kualitas hidup. Interleukin (IL)3 dan IL9 berperan dalam proses pembentukan eosinofil, sedangkan eosinofil diketahui berperan penting dalam menyebabkan keluhan hidung buntu dan kerusakan epitel mukosa hidung penderita rinitis alergi. Mometasone furoate merupakan kortikosteroid topikal generasi terbaru yang jarang menyebabkan efek samping.Tujuan: Penelitian ini bertujuan mengetahui perubahan kadar IL3, IL9-serum, dan jumlah eosinofil mukosa hidung sesudah pemberian semprot hidung mometasone furoate pada penderita rinitis alergi. Metode: Penelitian observasional analitik ini melibatkan 38 penderita rinitis alergi yang diberi semprot hidung mometasone furoate selama 2 minggu dengan dosis 200 µg/hari. Kadar IL3, IL9-serum, dan jumlah eosinofil mukosa hidung diukur sebelum dan sesudah perlakuan. Hasil: Data dianalisis dengan uji t-berpasangan dan uji Wilcoxon. Kadar IL3, IL9-serum, dan jumlah eosinofil mukosa hidung menurun secara bermakna (p <0,001) sesudah pemberian mometasone furoate topikal selama 2 minggu. Kesimpulan: Mometasone furoate semprot hidung terbukti berpengaruh terhadap penurunan kadar IL3, IL9-serum, dan jumlah eosinofil mukosa hidung pada penderita rinitis alergi. Penelitian lebih lanjut diperlukan untuk mengetahui pengaruh mometasone furoate topikal terhadap sitokin lain yang berperan pada rinitis alergi, pengukuran kadar IL3 dan IL9-mukosa hidung, dan hubungan kadar IL3 dan IL9-mukosa hidung dengan IL3 dan IL9-serum.Kata kunci: Rinitis alergi, IL3, IL9, eosinofil, mometasone furoate.
Hubungan status nutrisi penderita karsinoma nasofaring stadium lanjut dengan kejadian mukositis sesudah radioterapi Tricia, Fransiska; Rahaju, Pudji; Suheryanto, Rus
Oto Rhino Laryngologica Indonesiana Vol 42, No 1 (2012): Volume 42, No. 1 January - June 2012
Publisher : PERHATI-KL

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (1131.729 KB) | DOI: 10.32637/orli.v42i1.40

Abstract

Background: Normal nutritional status is a balanced condition of nutritional intake and requirement in a person. Lack of nutrition in cancer patients promotes undesirable effects on various organs and systems of the body. Purpose: To determine the nutritional status differences in patients with advanced stage NPC type III WHO before and after radiotherapy,  and the relationship between nutritional status with mucositis occurance after radiotherapy. Method: Observational analytic study. Sampling was conducted by non-random purposive sampling technique with 10 subjects with NPC. The statistical analysis used paired sample Wilcoxon test and Spearman correlation test. Result: The study found significant differences between nutritional state regarding BMI, LOLA and transferrin before and after radiotherapy with p<0.05. Paired sample t test of BMI, LOLA, transferrin before and after radiotherapy demonstrated BMI p=0.000, LOLA p=0.001 and transferrin p=0.005. The paired sample t test for albumin before and after radiotherapy showed that radiotherapy did not cause significant decrease in albumin. Correlation test to determine the relationship among BMI, LOLA, albumin, and transferrin before radiotherapy with mucositis occurance showed BMI p=0.062, LOLA p=0.209, p=0.904 albumin, transferrin p=0.631 which meant that nutritional state has no corelation with mucositis occurance. While after radiotherapy it showed BMI p=0.122, p=0.209 LOLA, albumin, p=0.902 and transferrin p=1.000 which meant that nutritional state after radiotherapy has no corelation to the occurance of mucositis. Conclusion: Radiotherapy in patients with advanced-stage of NPC caused a significant difference in nutritional state before and after radiotherapy, but had no significant association with mucositis occurance. Keywords: nasopharyngeal carcinoma, radiotherapy, nutritional state, malnutrition, mucositis Abstrak :  Latar belakang: Status nutrisi normal menggambarkan keseimbangan yang baik antara asupan nutrisi dengan kebutuhan nutrisi. Kekurangan nutrisi pada penderita kanker memberikan efek yang tidak diinginkan terhadap struktur dan fungsi hampir semua organ dan sistem tubuh. Tujuan: Penelitian ini untuk mengetahui perbedaan status nutrisi penderita karsioma nasofaring (KNF) WHO tipe III   stadium lanjut   sebelum dan sesudah radioterapi, hubungan status nutrisinya dengan kejadian mukositis sesudah radioterapi. Metode: Penelitian ini adalah observasional analitik, dengan jumlah sampel 10 penderita KNF. Analisis statistik menggunakan paired sample t test dan uji korelasi Spearman. Hasil: Terdapat perbedaan yang bermakna antara status nutrisi dengan parameter Body Mass Index (BMI), lingkar otot lengan atas (LOLA) dan transferin sebelum dan sesudah radioterapi (BMI p=0,000, LOLA p=0,001 dan transferin p=0,005 dengan p<0,05). Pada paired sample t test albumin sebelum dan sesudah radioterapi menunjukkan nilai p=0,205 yang berarti bahwa radioterapi tidak menyebabkan penurunan albumin yang bermakna. Uji korelasi hubungan antara BMI, LOLA, albumin, dan transferin sebelum radioterapi dengan kejadian mukositis menunjukkan bahwa status nutrisi tidak berhubungan dengan kejadian mukositis (BMI p=0,062, LOLA p=0,209, albumin p=0,904, transferin p=0,631 dengan p>0,05). Uji korelasi hubungan antara BMI, LOLA, albumin, dan transferinsesudah radioterapi menunjukkan bahwa status nutrisi tidak berhubungan secara signifikan dengan kejadian mukositis sesudah radioterapi (BMI p=0,122, LOLA p=0,209, albumin p=0,902 dan transferin p=1,000 dengan p>0,05) Kesimpulan: Pemberian radioterapi pada penderita KNF stadium lanjut menyebabkan penurunan bermakna pada status nutrisi sebelum dan sesudah radioterapi, tetapi tidak berhubungan secara bermakna dengan kejadian mukositis sesudah radioterapi.  Kata kunci: karsinoma nasofaring, radioterapi, status nutrisi, malnutrisi, mukositis.
Kadar reseptor glukokortikoid α dan β pada polip hidung tipe eosinofilik dan tipe neutrofilik Arif, Moch Mundir; Suheryanto, Rus; Lukmantya, Lukmantya; Anita, Kenty Wantri
Oto Rhino Laryngologica Indonesiana Vol 44, No 2 (2014): Volume 44, No. 2 July - December 2014
Publisher : PERHATI-KL

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (631.345 KB) | DOI: 10.32637/orli.v44i2.92

Abstract

Latar Belakang: Penatalaksanaan polip hidung banyak didasarkan pada tipe histopatologinya. Polip hidung tipe eosinofilik lebih sensitif terhadap pemberian kortikosteroid sedang tipe neutrofilik lebih resisten. Hasil pengobatan dengan kortikosteroid juga dipengaruhi oleh reseptor glukokortikoid (GR). Kadar reseptor glukokortikoid β yang tinggi  akan lebih resisten dibanding yang rendah. Rasio kadar reseptor glukokortikoid α dan β lebih berperan karena GR β bekerja menghambat GR α. Tujuan: Penelitian ini bertujuan mengetahui hubungan kadar reseptor glukokortikoid α dan β pada polip hidung tipe eosinofilik dan tipe neutrofilik. Metode: Penelitian observasional analitik dengan desain crosssectional. Hasil: Penelitian inimelibatkan 20 penderita polip hidung yang dilakukan biopsi atau operasi. Hasil biopsi atau operasi diperiksa jenis histopatologinya dan dihitung kadar reseptor glukokortikoid α dan β dengan pemeriksaan imunohistokimia. Data penelitian dianalisa dengan uji sampel t tidak berpasangan. Kadar reseptor glukokortikoid α pada polip hidung tipe eosinofilik didapatkan sama dengantipe neutrofilik. Kadar reseptor glukokortikoid β didapatkan lebih tinggi secara bermakna pada polip hidung tipe neutrofilik dibanding tipe eosinofilik. Rasio kadar GRα/GRβ lebih tinggi pada polip hidung tipe eosinofilik dibanding tipe eosinofilik tetapi perbedaannya tidak bermakna. Kesimpulan: penelitian ini kadar reseptor β lebih tinggi pada polip tipe neutrofilik dengan rasio kadar GRα/GRβ lebih tinggi pada polip hidung tipe eosinofilik. Penelitian lebih lanjut diperlukan menghitung kadar reseptor glukokortikoid α dan β lebih akurat dengan menggunakan teknik ELISA (RT-PCR).Kata kunci: Tipe polip hidung, reseptor glukokortikoid, imunohistokimia.ABSTRACTIntroduction: Management of nasal polyps is commonly based on its histopathologic type. Eosinophilic nasal polyps are more sensitive to corticosteroid administration, where as neutrophilic types are more resistant. Results of treatment with corticosteroid were also influenced by glucocorticoid receptor. Higher β Glucocorticoid Receptor (β GR) concentration render more resistency compared with lower one. Ratio of α and β GR was more meaningful because β GR acts to inhibit α GR. Purpose: This study aims todetermine relationship between α and β GR concentration in eosinophilic and neutrophilic nasal polyps. Methods: This is an observational analytic study with cross sectional design. Result: This study involves 20 patients with nasal polyp who underwent biopsy or operation. The biopsy or operation specimenswere then evaluated for its histopathologic type. The concentration of α and β GR was counted by immunohistochemistry. Data was analyzed with unpaired T-test. Concentration of α GR in eosinophilic nasal polyps was similar with neutrophilic type. Concentration of β GR in neutrophilic nasal polyps was significantly higher compared with neutrophilic type. Ratio of α GR/β GR concentration was higher in eosinophilic nasal polyps than eosinophilic, but insignificant. Conclusion: β GR concentration is higher in neutrophilic nasal polyps and ratio of α GR/β GR concentration is higher in eosinophilic nasal polyps. Further study is required to count α GR and β GR concentration more accurately using ELISA (RT-PCR).Keywords: Nasal polyps types, glucocorticoids receptors, immunohistochemistry.
Hubungan derajat adenoid menggunakan teknik nasoendoskopi dengan tekanan telingah tengah Rosmini, Rosmini; Suheryanto, Rus; Surjotomo, Hendradi
Oto Rhino Laryngologica Indonesiana Vol 46, No 2 (2016): Volume 46, No. 2 July - December 2016
Publisher : PERHATI-KL

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (1111.153 KB) | DOI: 10.32637/orli.v46i2.157

Abstract

Latar belakang: Hipertrofi adenoid sering dilaporkan sebagai salah satu faktor penyebab terjadinya disfungsi tuba. Hubungan anatomi antara nasofaring dan adenoid memiliki implikasi terhadap tuba Eustachius yang terletak di sebelah lateral. Akhir-akhir ini telah digunakan secara luas alat diagnostik endoskopi, salah satu di antaranya adalah pemeriksaan nasoendoskopi, yang dapat memberikan visualisasi 3 dimensi secara jelas, sehingga dapat menentukan derajat adenoid terhadap struktur anatomi sekitarnya. Sebagian besar penyakit telinga tengah didahului oleh gangguan fungsi tuba Eustachius. Fungsi ventilasi merupakan fungsi tuba Eustachius yang paling penting, bertujuan untuk mempertahankan keseimbangan antara tekanan gas dalam telinga tengah dan udara di luar membran timpani. Salah satu cara untuk mengukur tekanan telinga tengah secara tak langsung, yaitu dengan timpanometri yang dapat menilai fungsi ventilasi tuba Eustachius. Tujuan: Mengetahui hubungan derajat adenoid menggunakan nasoendoskopi dengan tekanan telinga tengah. Metode: Penelitian observasional analitik dengan desain cross sectional, melibatkan 24 sampel yang diduga menderita hipertrofi adenoid, yang dilakukan nasoendoskopi, dan tekanan telinga tengah diukur dengan timpanometri. Data penelitian dianalisis dengan uji korelasi Spearman. Hasil: Terdapat korelasi yang cukup kuat dan signifikan antara derajat adenoid dengan tekanan telinga tengah dan tipe timpanogram (p=0,027 dan p=0,002). Kesimpulan: Semakin tinggi derajat adenoid maka tekanan telinga tengah semakin turun. Dibutuhkan penelitian lebih lanjut untuk melihat hubungan antara derajat adenoid menggunakan nasoendoskopi dengan gejala klinis dari hipertrofi adenoid.Kata kunci: Derajat adenoid, nasoendoskopi, tekanan telinga tengah ABSTRACT Background: Adenoid hypertrophy has been widely reported as one of the causes of tubal dysfunction. Anatomical relationship between the nasopharynx and adenoid has implications for the Eustachian tube which is located at the lateral wall of the nasopharynx. Recently, endoscopic diagnostic tool has been commonly used, because it provides a clear 3-dimensional visualization, to determine the degree of adenoid hypertrophy with its’ surrounding anatomical structures. Most of the middle ear disease is preceeded by Eustachian tube dysfunction. Ventilation is the most important function of the Eustachian tube which aims to maintain the balance of the gas pressure in the middle ear and the air outside the tympanic membrane. Tympanometry is one of the tools for measuring the pressure of the middle ear which indirectly assesses the function of the Eustachian tube ventilation. Purpose: To determine the relationship between the degree of adenoid using nasoendoscopy with middle ear pressure. Method: The study was observational analytic with cross sectional design. This study involved 24 patients with adenoid hypertrophy underwent nasoendoscopic examination and tympanometry for assessing middle ear pressure. Data were analyzed using Spearman test. Result: There was a fairly strong and significant correlation between adenoid hypertrophy with middle ear pressure and tympanogram type (p=0.027 and p=0.002). Conclusion: The higher the degree of adenoid hypertrophy, the lower the middle ear pressure. Further research is needed to see the relationship of the degree of adenoid with nasoendoscopy with clinical symptoms of adenoid hypertrophy.Keywords: Degree of adenoid, nasoendoscopy, middle ear pressure
Peran β-glucan dalam diagnosis rinosinusitis kronik jamur Wicaksana, Dhaniel Abdi; Suheryanto, Rus; Maharani, Iriana
Oto Rhino Laryngologica Indonesiana Vol 48, No 1 (2018): Volume 48, No. 1 January - June 2018
Publisher : PERHATI-KL

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (366.964 KB) | DOI: 10.32637/orli.v48i1.254

Abstract

Latar Belakang: Rinosinusitis kronik jamur merupakan permasalahan kesehatan terutama dinegara berkembang karena prevalensinya yang semakin meningkat, sulitnya penanganan medis, sertaberdampak besar terhadap penurunan kualitas hidup. Saat ini tengah dikembangkan teknologi untukmembantu penegakan diagnosis tanpa tindakan invasif, yaitu dengan memanfaatkan β-glucan sebagaikomponen terbesar penyusun dinding sel beberapa spesies jamur. Tujuan: Mengetahui hubungan antarakadar β-glucan jaringan sinus dan serum darah untuk diagnosis rinosinusitis kronik jamur. Metode:Penelitian cross sectional ini melibatkan 20 subjek penelitian. Dilakukan pengambilan sampel darah, danpembedahan sinus maksila untuk mengambil jaringan mukosa, yang kemudian dilanjutkan pemeriksaanpolymerase chain reaction (PCR) untuk identifikasi jamur pada mukosa sinus. Bila didapatkan spesiesjamur yang memiliki β-glucan, dilakukan pemeriksaan enzyme-linked immunosorbent assay (ELISA) untukpengukuran kadar β-glucan. Hasil: Aspergillus flavus merupakan jamur yang paling banyak ditemukan.Seluruh subjek melampaui batasan positif β-glucan (≥80 pg/mL) dari spesimen mukosa, dan hanya 1subjek memberikan hasil intermediate (60-79 pg/mL) dari darah. Uji t berpasangan mendapatkan kadarβ-glucan darah tidak berbeda bermakna dengan mukosa sinus (p=0,886), sehingga pemeriksaan β-glucanpada darah dapat menggambarkan kadar β-glucan pada sinus paranasal. Kesimpulan: β-glucan dapatdimanfaatkan untuk membantu memperoleh diagnosis rinosinusitis kronik jamur, sehingga diharapkandiagnosis dapat ditegakkan dengan cepat dan tepat tanpa memerlukan tindakan invasif, namun hasil inimembutuhkan penelitian lebih lanjut, khususnya terkait uji diagnostik.  ABSTRACTBackground: Chronic fungal rhinosinusitis is a major health problem particularly in developingcountries due to its increasing prevalence, difficult medical treatment, and also could make a large impacton the quality of life. The current technology to establish diagnosis without invasive procedure is byutilizing β-glucan, the largest component of fungal cell wall in some fungal species. Purpose: To discoverthe correlation of β-glucan level in paranasal sinus tissue and blood serum as a potential diagnosismarker for chronic fungal rhinosinusitis. Methods: A cross sectional study involving 20 subjects. Bloodsampling and maxillary sinus surgery were performed, then fungi identification in the sinus mucosawas done by Polymerase Chain Reaction (PCR). If a fungal species with β-glucan was found, then theexamination was continued with the measurement of β-glucan by Enzyme-Linked Immuno Sorbent Assay(ELISA) technique in sinus and blood. Results: Aspergillus flavus is the most commonly found fungus. Allsubjects passed the positive β-glucan limit (≥80 pg/mL) of the mucosal sample, and only 1 subject hadintermediate results (60-79 pg/mL) from the blood. Paired t-test result showed no significant differencebetween the level of β-glucan in blood and mucosal sinus (p=0.886), so that β-glucan blood examinationcould illustrate β-glucan levels in paranasal sinuses. Conclusion: β-glucan may be used to establishthe diagnosis of fungal chronic rhinosinusitis with one hope that the diagnosis process can be obtainedquickly and accurately without invasive procedure, although it still requires more studies, particularlyrelated to diagnostic test.