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Fungal Sinusitis: An Overview. Cade Martin, MD. Fungal Sinusitis. 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

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fungal sinusitis
Fungal Sinusitis
  • 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
fungal sinusitis3
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
Fungal Sinusitis - Classification
  • Invasive
    • Acute Invasive Fungal Sinusitis
    • Chronic Invasive Fungal Sinusitis
    • Chronic Granulomatous Invasive Fungal Sinusitis
  • Noninvasive
    • Allergic Fungal Sinusitis
    • Fungus Ball (fungus mycetoma)
acute invasive fungal sinusitis
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
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
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, occlusion, or pseudoaneurysm
acute invasive fungal sinusitis ct
Acute Invasive Fungal Sinusitis - CT
  • Unilateral ethmoid involvement with bone destruction, intraorbital spread and proptosis
acute invasive fungal sinusitis mri
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 imaging10
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
slide11

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 treatment
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
chronic invasive fungal sinusitis
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 features
Chronic Invasive Fungal Sinusitis – Clinical Features
  • Usually immunocompetent
  • History of chronic rhinosinusitis
  • Usually persistent and recurrent disease
  • Maxillofacial 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
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 treatment
Chronic Invasive Fungal Sinusitis – Treatment
  • Surgical exenteneratin of affected tissues and systemic antifungal
  • Needs aggressive treatment
chronic granulomatous invasive fungal sinusitis
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 sinusitis19
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
allergic fungal sinusitis
Allergic Fungal Sinusitis
  • Most common form of fungal sinusitis
  • Common in warm, humid climates of Southern US
  • 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 clinical
Allergic Fungal Sinusitis - Clinical
  • Younger individuals, third decade, immunocompetent
  • Often associated history of atopy with allergic rhinitis or asthma
  • Chronic headaches, nasal congestion, and chronic sinusitis for years
allergic fungal sinusitis imaging
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 imaging24
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 treatment
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
fungus ball
Fungus Ball
  • Older individuals, female>male
  • Immunocompetent
  • Asymptomatic or minimal symptoms with chronic pressure or nasal discharge
  • Cacosmia (perception of foul odor when no such odor exists)
fungus ball27
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
Fungus Ball - CT
  • High density material with thickened walls of the maxillary sinus due to chronic inflammation
fungus ball treatment
Fungus Ball Treatment
  • Surgical Removal with restoration of drainage of the sinus
  • Antifungal medications usually unnecessary
  • Recurrence is rare