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Cade Martin, MD
• 400,000 known fungal species or which 400 are human pathogens and 50 of which cause systemic or CNS infection • Clinical presentation, imaging features, and treatment differ based on type of fungal sinusitis • Broadly categorized into invasive and noninvasive
submucosa. or blood vessels of the paranasal sinuses • Noninvasive – Absence of fungal hyphae within the mucosa and other structures of the paranasal sinuses . bone.Fungal Sinusitis • Invasive – Presence of fungal hyphae within the mucosa.
Classification • Invasive – Acute Invasive Fungal Sinusitis – Chronic Invasive Fungal Sinusitis – Chronic Granulomatous Invasive Fungal Sinusitis • Noninvasive – Allergic Fungal Sinusitis – Fungus Ball (fungus mycetoma) .Fungal Sinusitis .
Absidia.Acute Invasive Fungal Sinusitis • Most lethal form of fungal sinusitis – mortality 5080% • Rare in immunocompetent patients • Two clinical populations – Poorly controlled Diabetics – ususally caused by fungi of order Zymocycetes (Rhizopus. BMT. Rhizomucor. AIDS) – Aspergillus accounts for 80% of infection in this group . organ transplants. and Mucor) – Immunocompromised with severe neutropenia (chemotheraphy patients.
epistaxis progressing to proptosis. visual disturbance. headache. nasal congestion. facial pain. sinusitis. mental status changes. rapid orbital and intracranial spread resulting in death • Angioinvasion and hematogenous dissemination common • Present with fever.Acute Invasive Fungal Sinusitis Clinical • Necrotic nasal septum ulcer (eschar). seizures as spread occurs • 73% of patients with intracranial spread die .
occlusion.Acute Invasive Fungal Sinusitis Imaging • Noncontrast CT – Severe unilateral nasal cavity soft tissue thickening is most consistent (but nonspecific) early CT finding – Hypoattenuating mucosal thickening within lumen of paranasal sinus with rapid aggressive bone destruction of sinus walls occurs as disease progresses – Often unilateral involvement of ethmoids. sphenoids – These Fungi can also spread along vessels with spread beyond the sinus with intact bony walls – Intracranial extension can result in cavernous sinus thrombosis. carotid artery invasion. or pseudoaneurysm .
intraorbital spread and proptosis .CT • Unilateral ethmoid involvement with bone destruction.Acute Invasive Fungal Sinusitis .
thrombosis. extension to the left sylvian fissure and infratemporal fossa with cerebral infarctions.MRI Aspergillus involving the sphenoid sinus with invasion of the left cavernous sinus. .Acute Invasive Fungal Sinusitis .
Acute Invasive Fungal Sinusitis Imaging • MRI – better for evaluating intracranial and intraorbital extension – Evaluate for inflammatory change in orbital fat and extraocular muscles – Obliteration of periantral fat is a subtle sign of extension – Leptomeningeal enhancement progressing to cerebritis and abscess .
There is diffuse involvement of the muscles of mastication. .Aspergillus in left maxillary sinus with extension anterior and posterior to the retroantral space.
Acute Invasive Fungal Sinusitis Treatment • Aggressive surgical debridement and systemic antifungal therapy • Reversal of underlying cause of immunosuppression if possible • Recovery from neutropenia is most predictive of survival • Intracranial spread is most predictive of mortality .
Rhizopus.Chronic Invasive Fungal Sinusitis • Inhaled fungal organisms deposited in nasal passageways and paranasal sinuses • Progression over months to years with fungal organisms invading mucosa. Bipolaris. blood vessels. Aspergillus. submucosa. and bony walls • Organisms – Mucor. and Candida .
cranial neuropathies. can invade cribiform plate causing headaches. seizures.Chronic Invasive Fungal Sinusitis – Clinical Features • • • • Usually immunocompetent History of chronic rhinosinusitis Usually persistent and recurrent disease Maxillofacial soft tissue swelling. decreased vision. orbital invasion with proptosis. decreased mental status .
markedly decreased signal on T2 weighted images . bone involvement often gives mottled appearance with or without sclerosis – May mimic malignancy with masslike appearance and extension beyond sinus confines • MRI – decreased signal on T1.Chronic Invasive Fungal Sinusitis – Imaging • Noncontrast CT – Hyperattenuating soft tissue mass withing one or more of paranasal sinuses.
Chronic Invasive Fungal Sinusitis .
Chronic Invasive Fungal Sinusitis – Treatment • Surgical exenteneratin of affected tissues and systemic antifungal • Needs aggressive treatment .
Chronic Granulomatous Invasive Fungal Sinusitis • AKA primary paranasal granuloma and indolent fungal sinusitis • Primarily found in Africa (Sudan) and Southeast Asia. only few case reports in US • Immunocompetent • Caused by Aspergillus flavus • Characterized by noncaseating granulomas in the tissues .
Chronic Granulomatous Invasive Fungal Sinusitis • Chronic indolent course similar to chronic invasive fungal sinusitis • Considered by some as same entity as chronic invasive fungal sinusitis • Imaging characertistics are similar to those of chronic invasive fungal sinusitis • Often resembles a mass/neoplasms • Treatment is surgical debridement and systemic antifungals .
Curvularia. Alternaria. humid climates of Southern US • Hypersensitivity reaction to inhaled fungal organisms resulting in chronic noninfectious inflammatory reaction .Allergic Fungal Sinusitis • Most common form of fungal sinusitis • Common in warm.IgE type I immediate hypersensitivity and type III hypersensitivity are involved • Common organisms implicated – Bipolaris. Aspergillus. and Fusarium • “Allergic mucin” within affected sinus which is inspissated mucous the consistency of peanut butter with eosinophils on histology .
nasal congestion. third decade. and chronic sinusitis for years .Allergic Fungal Sinusitis Clinical • Younger individuals. immunocompetent • Often associated history of atopy with allergic rhinitis or asthma • Chronic headaches.
Allergic Fungal Sinusitis . and manganese concentrated by fungal organisms and also due to a high protein.Imaging • Usually bilateral with multiple sinuses involved if not pansinus involement • Often has a nasal component • Noncontrast CT – high attenuation allergic mucin within lumen of sinuses – can mimic a mucocele with expansion of the sinus • MRI – variable T1 appearance. low T2 signal (attributed to high concentration of iron. magnesium. low free water content of allergic mucin .
Imaging .Allergic Fungal Sinusitis .
or sinonasal polyposis .Imaging • Moderately high T1 signal.Allergic Fungal Sinusitis . mucocele. low T2 signal with expanded sinus can be seen in allergic fungal sinusitis.
Allergic Fungal Sinusitis Treatment • Surgical removal of allergic mucin with restoration of normal sinus drainage is goal • Longterm use of topical nasal steroids helps suppress the immune response and minimize recurrence • Topical or systemic antifungals are not indicated .
female>male • Immunocompetent • Asymptomatic or minimal symptoms with chronic pressure or nasal discharge • Cacosmia (perception of foul odor when no such odor exists) .Fungus Ball • Older individuals.
Fungus Ball • Mass within the lumen of paranasal sinus and is usually limited to one sinus • Frontal sinus most common followed by sphenoid sinus • Noncontrast CT – hyperattenuating mass often with punctate calcifications • MRI – variable T1 and hypointense T2 due to absence of free water. calcifications and paramagnetic metals also generate decreased T2 signal – no central enhancement to differentiate from neoplasm .
Fungus Ball .CT • High density material with thickened walls of the maxillary sinus due to chronic inflammation .
Fungus Ball Treatment • Surgical Removal with restoration of drainage of the sinus • Antifungal medications usually unnecessary • Recurrence is rare .