International Rhinologic Society Rhinology 0300-0729 2026 06 04 Global distribution of fungal rhinosinusitis EN S. ZhouKey Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education of Guizhou, Key Laboratory of Microbiology and Parasitology of Education Department of Guizhou, School of Public Health, School of Basic Medical Science, Guizhou Medical University, Guiyang, China Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands Radboudumc-CWZ Center of Expertise for Mycology, Radboudumc, Nijmegen, The Netherlands R. Kwizera Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda F. BongominDepartment of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom L. Okema Division of Otorhinolaryngology, Department of Surgery, Faculty of Medicine, Gulu University, Gulu, Uganda J. Okot Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda E.M. Alcanzo Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands B.E. Ekeng Department of Medical Microbiology and Parasitology, University of Calabar Teaching Hospital, Calabar, Nigeria Y. Kang Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education of Guizhou, Key Laboratory of Microbiology and Parasitology of Education Department of Guizhou, School of Public Health, School of Basic Medical Science, Guizhou Medical University, Guiyang, China D.W. Denning Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom S. de HoogKey Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education of Guizhou, Key Laboratory of Microbiology and Parasitology of Education Department of Guizhou, School of Public Health, School of Basic Medical Science, Guizhou Medical University, Guiyang, China Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands Radboudumc-CWZ Center of Expertise for Mycology, Radboudumc, Nijmegen, The Netherlands Foundation Atlas of Clinical Fungi, Hilvers S.A. Ahmed Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait Journal Article 3438 10.4193/RhinBackground: Fungal rhinosinusitis (FRS) comprises 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.