Supplementary materials for "Global distribution of fungal rhinosinusitis"

Background: Fungal rhinosinusitis (FRS) comprises diverse invasive and non-invasive subtypes with varying epidemiology and outcomes. Comprehensive global data comparing these subtypes has been lacking.Objectives: We performed a systematic review and meta-analysis to provide the distribution of FRS subtypes.Data sources: We systematically searched PubMed, Google Scholar, Web of Science, Scopus, Embase, PsycINFO, Global Health, Cochrane Library, and Health Technology Assessment Database. We included studies published from database inception to January 2024Study eligibility criteria: We included all types of studies that investigated human cases of FRS, regardless of age, exploring risk factors, clinical features, etiology, and treatments.Participants: Humans diagnosed with any subtype of FRS.Methods: The review followed PRISMA guidelines and was registered in PROSPERO (CRD42023481670). Screening, data extraction, and quality assessment were conducted independently by multiple reviewers. FRS cases were categorized into seven subtypes. Quantitative synthesis provided the global distributions. Meta-analyses and chi-square tests were performed to assess subtype variation across geographic and climatic regions.Results: A total of 2,031 studies comprising 40,860 cases across 77 countries were included. Non-invasive forms accounted for approximately 64% of cases, with Type 6 fungal ball (37%) and Type 5 (allergic FRS) (27%) being the most prevalent. Invasive subtypes were more frequent in tropical climates, with Type 1 (Hyperacute rhino-cerebral mucormycosis) representing the predominant invasive form. Type 1 differed from Type 2 (Acute invasive FRS) in risk factors (diabetes and COVID-19 vs. leukemia), geographic distribution, and mortality. Aspergillus species were identified in nearly 60% of cases overall. Aspergillus fumigatus was more prevalent in temperate and continental climate zones, while A. flavus was frequently found in dry and tropical regions. Non-invasive FRS showed high surgical cure rates (>64% requiring surgery alone), whereas invasive forms remained associated with substantial morbidity and mortality despite antifungal treatment.Conclusions: Fungal rhinosinusitis represents a substantial yet underrecognized global health concern, with non-invasive forms predominating and invasive subtypes causing considerable morbidity and mortality, especially in tropical regions. Notably, our findings reveal distinct geographic and climatic preferences for Aspergillus species: A. fumigatus in temperate and continental zones, whereas A. flavus in dry and tropical regions. This ecological divergence underscores the importance of environmental surveillance and climate-informed diagnostic strategies.