Fungal SinusitisDr Vasanthika Sanjeewanie Thuduvage Consultant ENT and Head & Neck Surgeon Senior Lecturer / Faculty of Medicine KDU

Fungal Sinusitis400,000 known fungal species or

which 400 are human pathogens and 50 of which cause systemic or CNS infection

Broadly categorized into invasive and noninvasive

Fungal Sinusitis

Invasive Presence of fungal hyphae within the

mucosa, submucosa, bone, or blood vessels of the paranasal sinuses

Noninvasive Absence of fungal hyphae within the

mucosa and other structures of the paranasal sinuses

Fungal Sinusitis - Classification Invasive

Acute Invasive Fungal Sinusitis Chronic Invasive Fungal Sinusitis Chronic Granulomatous Invasive Fungal

SinusitisNoninvasive

Allergic Fungal Sinusitis Fungus Ball (fungus mycetoma)

Fungus Ball

Older individuals, female>male ImmunocompetentMay have a history of trauma or

injury to sinusAsymptomatic or minimal symptoms

with chronic pressure or nasal discharge

Cacosmia (perception of foul odor when no such odor exists)

fumigatus and dematiaceous fungi most commonly cause fungal ball

Fungus Ball Mass within the lumen of paranasal sinus

and is usually limited to one sinus  peanut-butter like appearance Frontal/Maxillary 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

Noncontrast CT – hyperattenuating mass often with 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

Allergic Fungal Sinusitis Most common form of fungal sinusitis Common in warm, humid climates Hypersensitivity reaction to inhaled fungal

organisms resulting in chronic noninfectious inflammatory reaction - IgE type I immediate hypersensitivity and type III hypersensitivity are involved

Common organisms implicated – Bipolaris, Curvularia, Alternaria, Aspergillus, and Fusarium

“Allergic mucin” within affected sinus which is inspissated mucous the consistency of peanut butter with eosinophils on histology

Allergic Fungal Sinusitis - ClinicalYounger individuals, third decade,

immunocompetentOften associated history of atopy

with allergic rhinitis or asthmaChronic headaches, nasal

congestion, and chronic sinusitis for years

Allergic Fungal Sinusitis - 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, and manganese concentrated by fungal organisms and also due to a high protein, low free water content of allergic mucin

Allergic Fungal Sinusitis - Imaging

Allergic Fungal Sinusitis - Imaging

Moderately high T1 signal, low T2 signal with expanded sinus can be seen in allergic fungal sinusitis, mucocele, or sinonasal polyposis

Allergic Fungal Sinusitis - TreatmentSurgical 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

? Low dose oral steriods/ ? Immune therapy

Topical or systemic antifungals are not indicated

Acute Invasive Fungal Sinusitis Most lethal form of fungal sinusitis –

mortality 50-80% Rare in immunocompetent patients Two clinical populations

Poorly controlled Diabetics – ususally caused by fungi of order Zymocycetes (Rhizopus, Rhizomucor, Absidia, and Mucor)

Immunocompromised with severe neutropenia (chemotheraphy patients, BMT, organ transplants, AIDS) – Aspergillus accounts for 80% of infection in this group

Acute Invasive Fungal Sinusitis - Clinical Necrotic nasal septum ulcer (eschar),

sinusitis, rapid orbital and intracranial spread resulting in death

Angioinvasion and hematogenous dissemination common

Present with fever, facial pain, nasal congestion, epistaxis progressing to proptosis, visual disturbance, headache, mental status changes, seizures as spread occurs

73% of patients with intracranial spread die

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

Unilateral involvement of ethmoids, sphenoids

Intracranial extension can result in cavernous sinus thrombosis, carotid artery invasion, occlusion, or pseudoaneurysm

Acute Invasive Fungal Sinusitis - CT

Unilateral ethmoid involvement with bone destruction, intraorbital spread and proptosis

Acute Invasive Fungal Sinusitis - MRI

Aspergillus involving the sphenoid sinus with invasion of the left cavernous sinus, thrombosis, extension to the left sylvian fissure and infratemporal fossa with cerebral infarctions.

Acute Invasive Fungal Sinusitis - ImagingMRI – 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

Aspergillus in left maxillary sinus with extension anterior and posterior to the retroantral space. There is diffuse involvement of the muscles of mastication.

Acute Invasive Fungal Sinusitis - TreatmentAggressive surgical debridement and

systemic antifungal therapy  High doses of Amphotericin B (1-1.5

mg/kg/d) are recommended. Oral Itraconazole (400 mg/d) can replace Amphotericin B once the acute stage has passed

Reversal of cause of immunosuppression if possible

Intracranial spread is most predictive of mortality

Chronic Invasive Fungal Sinusitis Inhaled fungal organisms deposited

in nasal passageways and paranasal sinuses

Progression over months to years with fungal organisms invading mucosa, submucosa, blood vessels, and bony walls

Organisms – Mucor, Rhizopus, Aspergillus, Bipolaris, and Candida

Chronic Invasive Fungal Sinusitis – Clinical FeaturesUsually immunocompetentHistory of chronic rhinosinusitisUsually persistent and recurrent

diseaseMaxillofacial soft tissue swelling,

orbital invasion with proptosis, cranial neuropathies, decreased vision, can invade cribiform plate causing headaches, seizures, decreased mental status

Chronic Invasive Fungal Sinusitis – Imaging Noncontrast CT – Hyperattenuating soft

tissue mass withing one or more of paranasal sinuses, 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, markedly decreased signal on T2 weighted images

Chronic Invasive Fungal Sinusitis

Chronic Invasive Fungal Sinusitis – TreatmentSurgical exenteneratin of affected

tissues and systemic antifungalAmphotericin B (2 g/d) is

recommended; this can be replaced by Ketoconazole or Itraconazole

Needs aggressive treatment

Chronic Granulomatous Invasive Fungal Sinusitis

Primarily found in Africa (Sudan) and Southeast Asia, only few case reports in US

ImmunocompetentCaused by Aspergillus flavusCharacterized 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

Anti fungal treatment side effects Amphotericin B Acute renal failure, anemia,

agranulocytosis, acute liver failure, cardiopulmonary hypertension, and hemorrhagic gastroenteritis.

Itraconazole and fluconazole Drug-induced cardiac

dysrhythmias, hepatic dysfunction, urticaria, and anaphylaxis.

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