Global distribution of fungal rhinosinusitis.

Abstract

BACKGROUND: Fungal rhinosinusitis (FRS) comprises subtypes with varying epidemiology and outcomes. Global comparative data remain limited. METHODS: Following PRISMA guidelines (CRD42023481670), a systematic review and meta-analysis was conducted. Cases were categorized into seven subtypes to assess variation across regions. RESULTS: 2,031 studies (40,860 cases, 77 countries) were included. Non-invasive forms accounted for 60% (n=24,582) of cases, mainly fungal ball (35%, n=14,280) and allergic FRS (25%, n=10,302). Invasive subtypes were more frequent in tropical climates, with the hyperacute rhino-orbito-cerebral mucormycosis predominating. This subtype differed from acute and subacute invasive FRS in risk factors (diabetes and COVID-19 vs. leukemia) and geography. Aspergillus species appeared in ~60% of cases: A. fumigatus dominated in temperate/continental zones, while A. flavus was frequent in dry/tropical regions. Non-invasive FRS showed high surgical cure rates (>64%), whereas invasive forms had substantial morbidity and mortality. CONCLUSIONS: FRS represents a substantial yet underrecognized global health concern. Non-invasive forms are predominating, while invasive subtypes cause major morbidity and mortality, especially in tropical regions. Notably, our findings reveal distinct geographic and climatic preferences for Aspergillus species: A. fumigatus in temperate/continental zones and A. flavus in dry/tropical regions. This ecological divergence underscores the importance of environmental surveillance and climate-informed diagnostic strategies.