Fungal Sinusitis

DEPARTMENT OF E.N.T

Fungal Sinusitis
Invasive Fungal Sinusitis.(Fulminant sinusitis) Chronic invasive Sinusitis. Fungal Ball. Saprophytic Allergic fungal Sinusitis.

Fungal Sinusitis
Classification Immunological status Prognosis Treatment

Invasive

compromised

Guarded

Reversal of immunocompramise, Surgery, antifungal treatment

Surgery, antifungal agents Surgery Removal Surgery , Steroids, antifungal drugs

Chronic invasive Fungal ball Saprophytic Allergic Fungal Sinusitis

Normal Normal Normal Atopic

Good Good Good Good

Invasive Fungal Sinusitis

Invasive fungal Sinusitis is almost confined to patients with altered host defenses, such as Diabetic patients. Undergoing transplantation ( Bone marrow, liver, Kidney and so on) Leukemia. Primary or acquired immunodeficiency.

Fungal Species

Mucormycosis :

Aspergillosis

Order Mucorales Class Zygomycetes species Rhizopus oryzae Aspergillus flavus Aspergillus fumigatus

Invasive fungal Sinusitis

Mucormycosis Obliterative invasion.

Aspergillosis angioinvasive

Clinical Features
Fever. Symptoms of sinusitis , Orbital swelling, Facial pain and nasal congestion Anterior rhinoscopy, necrosis of nasal mucosa and edema. Anesthesia of nasal mucosa and cheek. There may be invasion through hard palate.

Diagnosis

DNE C.T. Scan. M.R.I Biopsy with special fungal stains. Culture with special fungal stains such as calcoflour white.

C.T.Scan

Metallic density area is seen in the maxillary antrum . This is due to crystallization of calcium salts within the mycotic mass.

C.T.SCAN

High-and low-density areas are noticed inside the left maxillary sinus. This gives a high index of suspicion for a fungal infection.

M.R.I

MRI findings are related to inspissated secretions. A T1-weighted image through the opacified sinus shows mucosal thickening with isointense signal that increased with contrast and a non-enhancible hypointense lumen. Proton density and T2-weighted images demonstrate a low-signal-intensity region bridging the sinus cavity. Normal mucous and bacterial secretions have high signal intensity related to the high water concentration. The low-signal regions are related to the fungal infection and dehydrated inspissated mucous, calcifications, and iron salt deposition

PAS

PAS (periodic acidSchiff) stain of sinus content shows septated hyphae branching at 45 degrees characteristic of aspergillosis.

Mucor

Aspergillus

Treatment
Reversal of underlying predisposing conditions. Systemic antifungal therapy. Surgical debridement.

Antifungal therapy
Systemic amphotericin B at I.V dosage of 0.8 to 1.5 mg/kg/day to total dose of up to 3g. Nephrotoxicity Fever, chills, nausea and hypotention. These complications can be reduced or eliminated with the use amphotericine B lipid complex.

Other drugs
Itraconozole (Argillosis ) Voriconozole.

Chronic Invasive fungal Sinusitis

Aspergillus flavus. Aspergillus fumigatus. Immunocompetent patients present with pain less proptosis. Indolent fungal sinusitis, with extention to orbit or palate

Diagnosis
Biopsy . Histologic picture is a granuloma in which giant cells contain hyphae.

Complications
Blindness. Cerebral extention.

Treatment
Surgical exenteration. Systemic anti fungal therapy.

Fungus Balls
Fungus balls (Mycetoma) are common and grow in the wet , moist cavities of the para nasal sinuses, irrespective of the immunological status of the host. Asymptomatic. Cause symptoms indistinguishable from chronic sinusitis.

Fungal species
A.flavus. A.fumigatus. Alternaria and mucor.

Histology

Tangled hyphae charectoristic of fungus balls

Treatment

Conservative surgical removal by endoscopic surgical techniques.

Saprophytic Fungal infection

Saprophytic Fungal infections occur when ubiquitous fungal spores land and germinate on mucus crusts which fail to clear the sinonasal cavity. Commonly seen after sinonasal surgery. Treatment removal of crust

Allergic Fungal sinusitis

Patients with AFS are atopic with nasal polyps. One third may have asthma.

Fungal species
The majority of fungal species are dematiaceous (darkly pigmented). Alternaria. Bipolaris Curvularia Aspergillus

Allergic Fungal sinusitis

Bony erosiosn is common on sinus C.T Scan. Inspissated mucus causes heterogeneous soft tissue density. Diagnosis is made histopathologically by noting allergic mucin characterized by inflammatory cells, Eosinophills and Charcot leyden crystals ( a by product of eosinophil degranulation)

Allergic Fungal sinusitis

In this allergic mucin hyphal elements are best appreciated with fungal stains.

Treatment
Conservative non mutilating removal of polyps and inspissated allergic mucin by FESS. Systemic steroids prednisone 60mg/day for several days and tapered off over 2-3 weeks. Endoscopic debridement.

Immunology
Increased IgE and IgG to the specific fungus. Increase in Serum IgE level. As allergic fungal sinusitis causes increase in IgG and IgE, Immunotherapy is helpful as it induces a specific IgG blocking antibody

Cavernous sinuses

The cavernous sinuses are irregularly shaped, trabeculated cavities located at the base of the skull. The cavernous sinuses are the most centrally located of the dural sinuses and lie on either side of the sella turcica. These sinuses are just lateral and superior to the sphenoid sinus and are immediately posterior to the optic chiasma, .

The cavernous sinuses

The cavernous sinuses receive venous blood from the facial veins (via the superior and inferior ophthalmic veins) the sphenoid and middle cerebral veins. The cavernous sinuses empty via the superior petrosal sinuses, into the inferior petrosal sinuses, then into the internal jugular veins and the sigmoid sinuses .

The cavernous sinuses

This complex web of veins contains no valves; Blood can flow in any direction depending on the prevailing pressure gradients. Since the cavernous sinuses receive blood via this distribution, infections of the face including the nose, tonsils, and orbits can spread easily by this route

Cavernous sinus

The internal carotid artery with its surrounding sympathetic plexus passes through the cavernous sinus. The third, fourth, and sixth cranial nerves are attached to the lateral wall of the sinus. The ophthalmic and maxillary divisions of the fifth cranial nerve are embedded in the wall,

Cavernous sinus thrombosis

Cavernous

sinus thrombosis (CST) is the formation of a blood clot within the cavernous sinus, The cause is usually from a spreading infection in the sinuses, ears, or teeth. Staphylococcus aureus and Streptococcus

Cavernous sinus thrombosis

Cavernous sinus thrombosis causes Decrease or loss of vision, Drooping or bulging eyes, Headaches, and paralysis of the cranial nerves which course through the cavernous sinus. This infection is life-threatening and requires immediate treatment, which includes antibiotics and Sometimes surgical drainage

Cavernous Sinus Thrombosis

This is one of the complication of infection of the paranasal sinuses. Ethmoid Sphenoid. Frontal Sinus. Orbital complications from these sinus infections can cause thrombophlebitis of the cavernous sinus.

Other causes
Source
Nose and danger area of face Ethmoid sinuses Sphenoid and frontal sinus

Disease
Furuncle and septal abscess Orbital cellulitis and abscess Sinusitis. Sinusitis and osteomyelitis of frontal bone Cellulitis and abscess Abscess Acute tonsilitis or Peritonsillar abscess Petrositis

Route
Pharyngeal plexus Ophthalmic veins Direct Supraorbital and ophthalmic vein Ophthalmic veins Angular and ophthalmic veinns Pharyngeal plexus Petrosal venous sinus

Orbit Upper lid Pharynx Ear

Clinical features
Onset is abrupt with chills and rigors. Acutely ill. Eyelids get swollen with chemosis and proptosis of the eye ball. III, IV, VI cranial nerves get involved individually and sequentially causing total ophthalmoplegia. Pupil gets dilated and fixed.

Clinical features
Optic disc is congested and edematous causing diminution of vision. Sensation in the distribution of Vi (ophtolmic branch of CNV) is diminished.

Diagnosis
C.S.F is normal C.T.Scan

Angiogram

Findings may include deformity of the internal carotid artery within the cavernous sinus, and an obvious signal hyperintensity within thrombosed vascular sinuses on all pulse sequences.

C.T.Scan

Sinus films are helpful in the diagnosis of sphenoid sinusitis. Opacification, sclerosis, and air-fluid levels are typical findings. Contrast-enhanced CT scan may reveal underlying sinusitis, thickening of the superior ophthalmic vein, and irregular filling defects within the cavernous sinus; however, findings may be normal early in the disease course.

C.T.Scan

Differential Diagnosis
Source
Source

Orbital cellulitis

Cavernous sinus Thrombosis

Commonly ethmoid Nose, sinuses, sinus orbit, ear, and pharynx.

onset

Slow; starts with edema of eye lids the inner canthus chemosis-proptosis Involved concurrently with complete ophthalmoplagia
Often involves one eye

Abrupt with high fever and chills with signs of toxemia edema of eye lids, chemosis and proptosis Involved individually and sequentially.
Involves both eyes

Cranial nerves involvement

Laterality

Treatment
I.V. antibiotics, after taking blood for culture, Treatment of focus of infection. Drainage of infected ethmoid and sphenoid sinus. Anti coagulants