Fungus balls of the paranasal sinuses

Anatomical Variations Associated With Maxillary Sinus Fungal Ball

OBJECTIVE

We investigated the anatomical and dental factors associated with unilateral maxillary sinus fungal ball (MSFB). Also, we evaluated the effect of combinations of those factors on the incidence of MSFB.

METHODS

Three hundred patients were divided into MSFB, normal, and chronic rhinosinusitis (CRS) groups. We reviewed paranasal computed tomography scans for the presence of deviated nasal septum, concha bullosa (CB), Haller cells, and various dental factors. Also, we measured the ethmoid infundibulum, maxillary natural ostium, and CB.

RESULTS

Maxillary sinus fungal ball showed a more significant association with CB compared to the other 2 groups (37%, P < .05). The MSFB group had a lower rate of Haller cells than the normal group (10% vs 22%, respectively; P < .05). Also, the MSFB group had a wider maxillary sinus ostium than the normal group (7.07 ± 1.8 vs 5.48 ± 1.3 mm; P < .01). Moreover, the combination of CB and Haller cells was significantly associated with a decreased rate of the fungal ball (P = .047, odds ratio = 0.694). The dental factors were more prevalent in the MSFB and CRS groups (73% and 75%, respectively) than in the normal group (32%, P < .001).

CONCLUSIONS

Maxillary sinus fungal ball is significantly associated with CB, Haller cells, an increased maxillary sinus ostium size, and dental factors.

Enhanced artificial intelligence-based diagnosis using CBCT with internal denoising: Clinical validation for discrimination of fungal ball, sinusitis, and normal cases in the maxillary sinus

BACKGROUND AND OBJECTIVE

The cone-beam computed tomography (CBCT) provides three-dimensional volumetric imaging of a target with low radiation dose and cost compared with conventional computed tomography, and it is widely used in the detection of paranasal sinus disease. However, it lacks the sensitivity to detect soft tissue lesions owing to reconstruction constraints. Consequently, only physicians with expertise in CBCT reading can distinguish between inherent artifacts or noise and diseases, restricting the use of this imaging modality. The development of artificial intelligence (AI)-based computer-aided diagnosis methods for CBCT to overcome the shortage of experienced physicians has attracted substantial attention. However, advanced AI-based diagnosis addressing intrinsic noise in CBCT has not been devised, discouraging the practical use of AI solutions for CBCT. We introduce the development of AI-based computer-aided diagnosis for CBCT considering the intrinsic imaging noise and evaluate its efficacy and implications.

METHODS

We propose an AI-based computer-aided diagnosis method using CBCT with a denoising module. This module is implemented before diagnosis to reconstruct the internal ground-truth full-dose scan corresponding to an input CBCT image and thereby improve the diagnostic performance. The proposed method is model agnostic and compatible with various existing and future AI-based denoising or diagnosis models.

RESULTS

The external validation results for the unified diagnosis of sinus fungal ball, chronic rhinosinusitis, and normal cases show that the proposed method improves the micro-, macro-average area under the curve, and accuracy by 7.4, 5.6, and 9.6% (from 86.2, 87.0, and 73.4 to 93.6, 92.6, and 83.0%), respectively, compared with a baseline while improving human diagnosis accuracy by 11% (from 71.7 to 83.0%), demonstrating technical differentiation and clinical effectiveness. In addition, the physician's ability to evaluate the AI-derived diagnosis results may be enhanced compared with existing solutions.

CONCLUSION

This pioneering study on AI-based diagnosis using CBCT indicates that denoising can improve diagnostic performance and reader interpretability in images from the sinonasal area, thereby providing a new approach and direction to radiographic image reconstruction regarding the development of AI-based diagnostic solutions. Furthermore, we believe that the performance enhancement will expedite the adoption of automated diagnostic solutions using CBCT, especially in locations with a shortage of skilled clinicians and limited access to high-dose scanning.

Imaging Findings in Aspergillosis: From Head to Toe

Aspergillosis is a mycotic infection induced by airborne fungi that are ubiquitous. Inhalation of Aspergillus conidia results in transmission through the respiratory tract. The clinical presentation is dependent on organism and host specifics, with immunodeficiency, allergies, and preexisting pulmonary disease constituting the most important risk factors. In recent decades, the incidence of fungal infections has increased dramatically, due in part to the increased number of transplants and the pervasive use of chemotherapy and immunosuppressive drugs. The spectrum of clinical manifestations can range from an asymptomatic or mild infection to a swiftly progressive, life-threatening illness. Additionally, invasive infections can migrate to extrapulmonary sites, causing infections in distant organs. Recognition and familiarity with the various radiological findings in the appropriate clinical context are essential for patient management and the prompt initiation of life-saving treatment. We discuss the radiological characteristics of chronic and invasive pulmonary aspergillosis, as well as some of the typically unexpected extrapulmonary manifestations of disseminated disease.

Correlational Analysis of Nasal Resistance and Acoustic Rhinometry Measurements With the Localization of Fungus Balls in the Paranasal Sinuses

Objective: To investigate the reason for fungal balls (FBs) being localized in paranasal sinuses, we analyzed the clinical presentations of patients with FB rhinosinusitis (FBS). Methods: Clinical data, anatomical variation (ie, nasal septal deviation, concha bullosa, and Haller cell), as well as measurements of nasal resistance (NR), nasal cavity volume (NCV), and nasal cross-sectional area (NCA) using active anterior rhinomanometry and acoustic rhinometry were collected from FBS patients hospitalized in our hospital between January 2021 and December 2022. A retrospective analysis was conducted using IBM SPSS 19.0 to perform the Shapiro-Wilk test, t-test and logistic regression analysis. Results: A total of 95 FBS patients, including 33 male and 62 female patients, were included in this study. FBs in maxillary sinus were the most common (83, 87.4%), followed by sphenoid sinus (9, 9.5%). Logistic multivariate regression analysis revealed that a higher left-to-right NR ratio was associated with an increased likelihood of FBs being present in the left sinus [Odds ratios (OR) = 0.185; 95% CI, 0.061-0.558; P < .01]. When the ratio of the left-to-right second-minimum NCA was higher and the FB was more in the right sinus (OR = 3.194; 95% CI, 1.593-6.405; P = .001). Additionally, when the difference between left and right NCV was greater and FB occurred more commonly in the right sinus (OR = 1.435; 95% CI, 1.196-1.721; P < .001). Nonetheless, the presence of nasal septum deviation and concha bullosa did not significantly contribute to FB formation. Conclusions and significance: The differences in NR, NCA, and NCV between the affected and unaffected sides of nasal cavity are risk factors for the FB formation. To reduce FBS recurrence, it is important to focus on improving nasal ventilation during the surgical treatment.

A Case of Fungal Maxillary Sinusitis Extending to the Contralateral Side Through the Nasal Septum

Fungal rhinosinusitis (FRS) presents as various phenotypes ranging from asymptomatic colonization to life-threatening infections. Here, we report an atypical case of FRS of the left maxillary sinus that extended to the contralateral maxillary sinus through the nasal septum. An 80-year-old woman with a history of osteoporosis was referred to our hospital for further management of headaches and chronic rhinosinusitis. Computed tomography (CT) of the sinus revealed a mass lesion with calcification in the left maxillary sinus, extending to the contralateral maxillary sinus through the nasal septum. T1-weighted and T2-weighted magnetic resonance imaging revealed a mass lesion with low-intensity signals. Endoscopic sinus surgery was performed for the diagnosis and treatment. Histopathological examination revealed fungal elements in the caseous material of the left maxillary sinus. However, no tissue-invasive fungal forms were found. Additionally, eosinophilic mucin was not observed. Based on these findings, the patient was diagnosed with fungus ball (FB). To the best of our knowledge, there are no reports of a FB extending contralaterally through the nasal septum. This report serves as a reminder that FB can extend into contralateral paranasal sinuses through the nasal septum and the possibility that osteoporosis is a cause of extensive bone destruction.

Incidence and Prevalence of Fungal Sinusitis in Cases of Chronic Rhinosinusitis

To study the incidence and prevalence of fungal sinusitis and its variants in cases of chronic rhinosinusitis in department of ENT and Head and Neck surgery. The study group consisted of 100 patients of chronic rhinosinusitis attending the outpatient and inpatients in department of Otorhinolaryngology. History was taken and diagnostic nasal endoscopy was performed. Patients underwent endoscopic sinus surgery and systemic treatment when required. Pre surgery serum IgE and post-surgery Histopathology was sent. Out of 100 patients, Males > Females and median age was 45.50 years (range 34.25-59.25 years). On DNE, 88% had polyps with 88.1% males and 87.8% females in their respective groups. 47% had allergic mucin with 49.2% males and 43.9% females in their respective groups. 34% had discharge with 28.8% males and 41.5% females in their respective groups. 37% had fungal filaments with 37.3% males and 36.6% females in their respective groups. 26% had fungal sinusitis in our study among which 53.8% were males and 46.1% were females. Peak fungal sinusitis was in 3rd to 5th decade. Commonest organism isolated was Aspergillus. Serum IgE was higher in patients with fungal sinusitis and nasal polyposis. In conclusion, the proportion of patients with Fungal Sinusitis was 26% among 100 patients with chronic rhinosinusitis. We isolated Aspergillus as the predominant fungus followed by Biporalis and Mucorales genus. Serum IgE was higher in patients with fungal sinusitis and Nasal polyposis. Both immunocompromised and competent individuals were managed surgically and/or medically when required. Our study showed that early fungal sinusitis detection leads to better management practices and prevents its progression into more severe disease with complications.

[Mycosis of the maxillary sinus]

In the structure of morbidity and mortality has significantly increased the role of mycoses. The increase in their spread is due not only to the improvement of the quality of diagnosis, but also the emergence of new strains resistant to previously used antifungal drugs, a significant change in the immune status of the population. In addition to environmental factors, it is important to introduce modern methods of treatment that increase survival in the whole spectrum of diseases. This situation can't affect the structure of diseases of ENT organs: the number of mycoses has increased significantly in recent decades. The issues of diagnosis and treatment of mycoses of the paranasal sinuses continue to be an urgent problem of otorhinolaryngology. The reason for this is a number of difficulties associated with the diagnosis: the absence of specific symptoms of the disease, the possible secondary nature of the attachment of fungal infection against the background of bacterial lesions, transient carrier of infection, technical difficulties and errors in the study of biomaterial with insufficient standardization of microbiological methods. Our report is devoted to the clinical case of aspergillosis of the maxillary sinus and a review of the literature on this issue, which in our opinion can be very interesting to the medical community.

A Multi-Institutional Database Review of Orbital Complications and Survival Outcomes in Adult Patients with Invasive or Non-Invasive Fungal Rhinosinusitis

BACKGROUND

Invasive fungal rhinosinusitis (IFS) with orbital complications has remained a challenging disease over the past few decades. Only a few studies have been conducted to investigate the factors associated with orbital complications in fungal rhinosinusitis (FRS). We aimed to review the characteristics between IFS and non-invasive fungal rhinosinusitis (NIFS) and determine clinical factors associated with orbital complications and overall survival.

METHODS

A multi-institutional database review study was conducted using the Chang Gung Research Database (CGRD) from January 2001 to January 2019. We identified FRS patients using International Classification of Diseases diagnosis codes and SNOMED CT. We categorized patients into IFS and NIFS groups and analyzed the demographic data, underlying diseases, clinical symptoms, laboratory data, image findings, fungal infection status, and survival outcomes.

RESULTS

We included 1624 patients in our study, with 59 IFS patients and 1565 NIFS patients. The history of an organ or hematopoietic cell transplantation had a significant prognostic effect on the survival outcomes, with surgical intervention and high hemoglobin (Hb) and albumin levels recognized as positive predictors. Posterior ethmoid sinus involvement, sphenoid sinus involvement, facial pain, blurred vision, and periorbital swelling were risk factors of orbital complications.

CONCLUSIONS

In NIFS patients, orbital complications were found to be associated with old age, a high WBC count, high blood glucose, and a high CRP level. For the risk factors of orbital complications in IFS patients, posterior ethmoid sinus involvement, sphenoid sinus involvement, facial pain, blurred vision, and periorbital swelling were recognized as predictors. Among IFS patients, a history of organ or hematopoietic cell transplantation was a risk factor for poor survival, while, conversely, surgical intervention and high Hb and albumin levels were related to improved survival. As predictors of orbital complications in IFS patients, posterior ethmoid sinus involvement, sphenoid sinus involvement, facial pain, blurred vision, and periorbital swelling upon the first visit should raise attention, with close monitoring.

Oro-Antral Fistulas and their Management: Our Experience

Oroantral fistula (OAF) is an epithelized, pathological communication between the maxillary antrum and oral cavity. The most common etiological factor is molar or premolar tooth extraction. The bone between maxillary sinus floor and posterior teeth is thin and occasionally the root apices of the posterior teeth reach the maxillary sinus, predisposing them to the formation of OAF. Other causes are bacterial or fungal infections, osteomyelitis, granulomatous diseases, Paget's disease, malignancy, maxillofacial trauma and iatrogenic. Small OAFs heal spontaneously but larger fistulas, persisting more than three weeks need to be closed. In repairing the persistent OAF, the maxillary sinus must be addressed. Maxillary sinusitis may lead to the failure of closure of the OAF. The basic modus operandi is clearance of disease from the sinus and covering the defect with a suitable graft. Various local and distant flaps are used to repair the OAF. We report three cases of OAF, managed by three different techniques. We also suggest a combined approach for large OAFs, repaired in 3 layers using septal cartilage, fat, and a buccal muco-periosteal advancement flap.

Case of maxillary actinomycotic osteomyelitis, a rare post COVID complication-case report

Introduction

and Importance: Maxillary actinomycosis is a persistent, very rare disease produced by Actinomyces species which may include only soft tissue or bone or the two together. Actinomycotic osteomyelitis of maxilla is very infrequent when compared to mandible.

Case presentation

Here we are conferring a case of an elderly male patient who had history of COVID-19 infection 4 months ago, with constant complaint of non-remitting vague pain in the region of maxilla with tooth loosening and extractions. He was given a provisional diagnosis of chronic osteomyelitis of maxilla which was later on proved by histopathology as actinomycotic osteomyelitis.

Clinical discussion

A saprophytic fungus causes mucor mycosis, and it is quite unusual. Strawberry gingivitis is one of the signs and symptoms. Mucormycosis and post-covid oral maxillofacial problems can be improved with early diagnosis. Oral Mucormycosis should be suspected in individuals with weakened immune systems, uncontrolled diabetes or post-covid instances. Surgery and adequate antibiotic treatment are necessary to treat actinomycosis. Infection may return after a period of inactivity, so long-term follow-up is necessary.

Conclusion

We conclude a positive causal association between COVID-19 and actinomycosis. Maxillary osteomyelitis, a very rare infection, and in our case, the causative organism was Actinomyces Patients who have been infected should be tested for Actinomycin, which may masquerade as a head and neck illness.

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Osteomyelitis caused by fungus is a potentially fatal opportunistic illness that is extremely rare. The orofacial region is usually affected, particularly the nose and paranasal sinuses. It's a dangerous infection that must be treated right away if it isn't to become fatal.

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Thrombosis and necrosis of adjacent hard and soft tissues occur as a result of vascular tissue invasion upon inhalation of the pathogen. Infection begins in the nose and paranasal sinuses and progresses to the lungs.

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We Present an old male patient with history of COVID-19 infection with chronic non-remitting nonspecific discomfort in the region of maxilla with teeth loosening and extractions.

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Histopathology later revealed that he had actinomycotic osteomyelitis, which was initially diagnosed as chronic maxillary osteomyelitis.

Analysis of predisposing factors in unilateral maxillary sinus fungal ball: the predictive role of odontogenic and anatomical factors

BACKGROUND

The pathogenesis of maxillary sinus fungal ball (MSFB) is explained by aerogenic and odontogenic factors. We evaluated the predisposing factors, including intranasal anatomical and dental factors for increased diagnostic accuracy.

METHODOLOGY

In this study, 117 patients who underwent endoscopic sinus surgery for unilateral MSFB were included. Preoperative computed tomography (CT) scans were used to analyze the presence of anatomical variations (anterior and posterior nasal septal deviation (NSD), concha bullosa (CB), infraorbital cell (haller cell), paradoxical middle turbinate, everted uncinate process and MS size). Dental factors including history of dental procedures and findings on CT scans were reviewed.

RESULTS

Anterior and posterior NSD toward non-affected side were significantly associated with the presence of FB. The presence of CB and infraorbital cell was higher in the non-affected side rather than in the lesion side. Compared to non-affected MS, FB-presence MS was shallower and had a larger height to depth ratio. The presence of dental history was significantly higher on FB-presence MS than non-affected MS. In multivariable analysis, posterior NSD toward non-affected side, dental history increased the aOR of MSFB, while the presence of CB and infraorbital cell decreased the aOR of MSFB.

CONCLUSIONS

The occurrence of MSFB seems to be associated with ipsilateral odontogenic factors, followed by anatomic variations including posterior NSD toward non-affected side and absence of CB and infraorbital cell.

High CT Attenuation Values Relative to the Brainstem Predict Fungal Hyphae Within the Sinus

Objectives

There is currently no established objective diagnostic indicator for the differentiation of sinus fungal ball (SFB) from unilateral nonfungal chronic sinusitis (UCRS). This study evaluated whether computed tomography (CT) attenuation values relative to those of the brainstem (relative CT number) are useful for differentiating SFB from UCRS.

Materials and Methods

Consecutive patients who were pathologically diagnosed with SFB or UCRS between 2013 and 2021 were retrospectively identified. The relative CT numbers of region of interest (ROIs) within the sinuses were compared between the two patient groups. Factors with predictive power for differentiating SFBs from UCRSs were identified by uni/multivariable logistic regression analyses.

Results

One hundred and eighty-three patients with unilateral chronic sinusitis were finally analyzed (SFB, 86 cases; UCRS, 97 cases). Regardless of the presence or absence of calcified lesions, the relative CT numbers in SFB were significantly higher than those in UCRS. ROIs showing high relative CT numbers were those where fungal hyphae were present. In the uni/multivariable logistic regression analysis, age (p < 0.001), relative CT number (p < 0.001), and calcification (p = 0.002) had predictive value for distinguishing SFB from UCRS. Within those cases not showing calcification, age (p = 0.004) and relative CT number (p < 0.001) were predictive factors for differentiating SFB from UCRS. A relative CT number >1.5 was significantly associated with SFB (sensitivity, 70%; specificity, 91%), with a significantly larger area under the receiver operating characteristics curve than age.

Conclusions

High relative CT numbers within the sinus are strongly associated with the presence of fungal hyphae, and measurement of relative CT number is a powerful adjunctive diagnostic method for distinguishing between SFB and UCRS.

Management of Fungal Rhinosinusitis: Experience From a Tertiary Care Centre in North India

Introduction

Fungal rhinosinusitis (FRS) has increased over the past few decades due to the rampant use of antibiotics, steroids, immunosuppressive drugs, increased incidence of HIV and uncontrolled diabetes. The current study reviews the types, clinical presentation, microbiology, histopathology and outcomes related to FRS in a tertiary care center in North India.

Methods

We retrospectively reviewed the clinical and follow-up records of patients diagnosed with FRS over three years. The data reviewed included clinical workup, ophthalmological profile, comorbidities, immunological status, radiological investigations, intraoperative and histopathological findings, treatment and follow-up records. In addition, we performed a descriptive analysis of the reviewed data.

Results

The study consisted of 30 FRS patients (16 male, 14 female). In that, 77% of cases were of allergic FRS, while fungal ball, chronic invasive, chronic granulomatous and acute invasive FRS represented 3%, 10%, 3% and 7% cases, respectively. The most common presentation in non-invasive forms was nasal obstruction, nasal discharge, hyposmia and polyposis, while it was facial pain and headache in the invasive varieties. After appropriate medical and surgical management through endoscopic sinus surgery, the recurrence rate in non-invasive and invasive fungal sinusitis was 16.6% and 20.8%, respectively. There was nil mortality at a minimum of one year of follow-up.

Conclusion

The non-invasive forms of FRS are common and have a relatively mild course. Early medical and surgical intervention and management of the underlying comorbidities are the key factors in managing invasive FRS. Close follow-up after surgery is also necessary for the timely detection and management of recurrences.

Fungal ball in concha bullosa as incidentaloma: A case report and the review of the literature

Concha bullosa is an anatomic variant consisting in an enlargement and pneumatization of the middle nasal turbinate. A fungal ball (FB) localized in this structure is an extremely rare disease. This article describes the unusual case of a young patient with an asymptomatic fungal mass in the concha bullosa, incidentally discovered at computed tomography (CT) scan of the head, which was performed after trauma.

Mucormycotic osteomyelitis of maxilla post-COVID patient: a case report

Fungal osteomyelitis is a life-threatening and seldom seen opportunistic infection. It is commonly an affectation of the nose and paranasal sinuses within the orofacial region. It is an aggressive infection that needs to be addressed promptly to prevent fatal consequences. The mode of infection is via the inhalation route and infection begins initially in the nose and paranasal sinuses with subsequent invasion into the vascular tissue, eventually leading to thrombosis and necrosis of nearby hard and soft tissues. Here, we report a case of a 31-year-old male who presented with pain over the upper jaw that was sudden in onset, continuous, dull aching, radiating towards forehead and neck of the left side, aggravates on mastication and relives on its own. He had a history of uncontrolled diabetes mellitus. On further investigation, using diagnostic and Interventional aids, a final diagnosis of mucormycotic osteomyelitis of the maxilla was made.

Unusual Location of a Fungus Ball: The Concha Bullosa, a Review of the Literature

Introduction

The fungal balls of the paranasal sinuses are usually seen in the maxillary and sphenoid sinuses. Although, the lesion of the concha bullosa, without sinus participation, is very uncommon. We report the case of a fungal ball of concha bullosa in an 88-year-old patient.

Objective

The objective of our review of literature is to investigate the epidemiological, clinical, paraclinical, and therapeutic characteristics of patients diagnosed with fungus ball in concha bullosa.

Methods

A case of a patient who was diagnosed with concha bullosa of a fungus ball is reported. Demographic data, clinical presentation, imaging, and treatments were recorded. Key images were obtained. A review of the literature was also performed.

Results

A total of 12 cases have been reported so far in the literature revealed by different symptoms. The mean age was 38.8 years and the gender ratio was ∼12 (female):1 (male). The endoscopic surgical approach was the most frequently used treatment and provides good outcomes. Neither postoperative complications nor recurrences were noted, however, there is insufficient follow-up data.

Conclusion

Concha bullosa fungal ball is a rare diagnosis that can be revealed by different symptoms. It should be considered in patients with and unexplained chronic facial pain. A preoperative computed tomography scan is an essential tool in making a diagnosis. Endoscopic surgery is the treatment of choice, with a low morbidity and recurrence rate.

A 10-year-old immunocompetent girl with endogenous fungal endophthalmitis: Report of a case and review of the literature

Endogenous Endophthalmitis (EE) is a rare cause of blindness in the pediatric age group and this may account for the paucity of management guidelines in the literature. In this report, we describe our experience with a 10-year-old immunocompetent female who developed EE and became blind because of rapidly progressive and destructive inflammatory changes in her eye in spite of seemingly timely treatment.

Isolated fungus ball in a single cell of the left ethmoid roof: A case report

BACKGROUND

Isolated fungus ball (FB) in a single cell of the left ethmoid roof is a very rare condition.

CASE SUMMARY

We report the case of a 51-year-old female patient whose computed tomography presented a soft tissue mass filling in the left ethmoid roof cell. The patient did not complain of any specific sinonasal symptoms, such as nasal discharge, nasal obstruction, and loss of smell, apart from headache in the left retro-orbital region.

CONCLUSION

The patient underwent functional endoscopic sinus surgery under general anesthesia, and the inflammatory material collected was histologically diagnosed as a rare case of a FB in a single cell of the left ethmoid roof.

Invasive Klebsiella syndrome with coexisting fungal endophthalmitis

Endogenous endophthalmitis accounts for approximately 5 - 10% of all endophthalmitis cases. We report a case of a middle-aged gentleman with underlying uncontrolled diabetes mellitus who presented with fever and generalised body weakness for one week. He was diagnosed with invasive Klebsiella syndrome based on blood culture with presence of bilateral pleural effusion, liver abscess, renal impairment and sphenoidal sinusitis. The patient developed sudden bilateral painless reduced vision on day two of admission. Ocular examination revealed bilateral severe anterior chamber reaction and severe vitritis that obscured the view of the fundus. Ocular B-scan ultrasonography showed multiple loculations in the posterior segment in both eyes. There was soft tissue density with calcification in the left sphenoid sinus on computed tomography of the orbit. He was treated for bilateral endogenous endophthalmitis with multiple intravitreal antibiotic injections, but showed no improvement. Functional endoscopic sinus surgery was performed and revealed that the left sphenoid sinus was filled with fungal balls. Following drainage of sphenoidal pus, there was resolution of vitritis and fundus examination showed features of underlying fungal infection with a "string of pearls" present along the vascular arcade of both eyes. The patient was diagnosed with bilateral endogenous endophthalmitis secondary to invasive Klebsiella syndrome with coexisting fungal endophthalmitis secondary to sphenoid mycetoma. In addition to repeated intravitreal antibiotic injections, he was also treated with systemic and topical antifungal therapy. At three months post treatment, the infection resolved and his vision improved from counting fingers to 6/36 bilaterally. Key messages: A middle-aged gentleman presented with bilateral endogenous endophthalmitis secondary to invasive Klebsiella syndrome with coexisting fungal endophthalmitis secondary to sphenoid mycetoma. A high index of suspicion is required for early diagnosis of fungal endophthalmitis.

Concurrent diagnosis of sinus fungus ball and invasive fungal sinusitis: A retrospective case series

BACKGROUND

Sinus fungal ball (SFB) is the most common type of non-invasive fungal sinusitis and develops mostly in immunocompetent individuals, whereas invasive fungal sinusitis (IFS), with high mortality, develops mostly in immunocompromised patients. SFB may progress to IFS depending on the patient's immune status and underlying diseases.

OBJECTIVES

To investigate the possibility of SFB progressing to IFS.

PATIENTS/METHODS

A total of 10 patients histopathologically diagnosed with concurrent IFS and SFB from January 2013 to December 2019 were enrolled. Their clinical characteristics, histopathology and clinical course information were obtained and compared with those of 56 patients with IFS alone and 617 patients with SFB alone.

RESULTS

Acute, chronic and chronic granulomatous IFS was diagnosed in two (20%), five (50%) and three (30%) patients, respectively. All patients had severe facial pain and/or headache, with the most common comorbidity being diabetes (n = 5, 50%). SFB was identified in the maxillary (60%) and sphenoid (40%) sinuses. The tissue culture was positive for Aspergillus species in five (50%) patients. Eight patients with chronic or chronic granulomatous IFS were successfully treated by debridement with voriconazole, and the two patients with acute IFS and severe neutropenia due to haematologic malignancy died. Compared to patients with IFS alone, patients with combined SFB and IFS were older, female dominant, and commonly had chronic or chronic granulomatous IFS. In addition, they were older and more commonly diabetic and immunocompromised than patients with SFB alone.

CONCLUSIONS

SFB may progress to IFS particularly in elderly and immunocompromised patients.

Clinical features in maxillary sinus fungus ball in patients with malignant hematological disease

PURPOSE

Previous studies on fungus balls have primarily focused on immunocompetent patients, and only a few studies have described the clinical characteristics of fungus balls in malignant hematological disease (MHD) patients. Therefore, we compared the clinical features of maxillary sinus fungus ball (MSFB) between immunosuppressive patients with MHD and immunocompetent patients.

METHODS

Twenty patients with MHD and 40 randomly selected immunocompetent patients were enrolled and divided into MHD and non-MHD groups. All patients were diagnosed with MSFB and their clinical features were retrospectively analyzed.

RESULTS

Patients in the MHD group had non-specific clinical symptoms and endoscopic manifestations of MSFB, similar to those in the non-MHD group. On computed tomography (CT), the MHD group showed higher Lund-Mackay scores, lesser single sinus opacifications, more multiple sinus opacifications on the affected side, and more bilateral opacifications compared to the non-MHD group. The MHD group had a lower frequency of central hyper-density and heterogeneous opacifications than the non-MHD group. There were no significant differences between the two groups in terms of the fungal-infected side, lateral sinus wall ratio, sclerosis of the lateral sinus wall, erosion of the inner sinus wall, and nasal septum deviation.

CONCLUSION

The clinical symptoms and endoscopic manifestations of MSFB in patients with MHD were similar to those of immunocompetent patients. However, more atypical signs and wider mucosal inflammation were found on CT scans of MSFB patients with MHD. These results indicate that caution should be executed when excluding the possibility of fungus balls in immunosuppressive patients.

Removal of fungal ball from the jaws by lefort i osteotomy: Difficulty in diagnosing patients with chronic sinusitis

Aspergillosis, aka fungal ball (FB), is classified as a type of non-invasive fungal rhinosinusitis, which usually occurs unilaterally in the maxillary sinus of an immunocompromised patient. Its diagnosis is complex and depends on the association between clinical, imaging, and histopathological exams. There are many treatments for fungal infections of the paranasal sinuses, so early diagnosis is extremely important to determine the appropriate treatment. This paper reports an unusual clinical case of aspergillosis present bilaterally inside the maxillary sinuses of a healthy patient, associated with mucous retention cysts, whose imaging exams and transnasal endoscopy were not sufficient to precisely identify the lesion. Its diagnosis and definitive treatment were obtained only after orthognathic surgery and integration between a multidisciplinary team. Key words:Aspergillosis, communicable diseases, fungal ball, infectious disease, orthognathic surgery.

Characteristic features of fungus ball in the maxillary sinus and the location of intralesional calcifications on computed tomographic images: A report of 2 cases

This report presents 2 cases of sinus fungus ball and describes the characteristic radiographic features of fungus ball in the maxillary sinus. Two female patients, aged 62 and 40 years, sought consultations at a dental hospital for the treatment of dental implants and tooth pain, respectively. Panoramic radiography and small field-of-view (FOV) cone-beam computed tomography (CBCT) did not provide detailed information for the radiographic diagnosis of fungus ball due to the limited images of the maxillary sinus. Additional paranasal sinus computed tomographic images showed the characteristic features of fungus ball, such as heterogeneous opacification and intralesional calcification of the maxillary sinus. The calcified materials of the fungus balls were located in the middle and superior regions of the maxillary sinus. It is necessary to use large-FOV CBCT for the detection of calcified materials in the upper maxillary sinus to confirm the diagnosis of fungus ball.

A Rare Cause of Headache That Should Be Kept in Mind: Isolated Concha Bullosa Fungus Ball

Concha bullosa is characterized by pneumotization of the middle turbinate and is a common variation of sinonasal anatomy and is often asymptomatic. The presence of a fungus ball in concha bullosa and the associated clinic symptoms are very rare. Concha bullosa fungus balls are a rare differential diagnosis in a patient presenting to the otorhinolaryngology outpatient clinic with headache.In this article, the authors aimed to present an isolated fungus ball case in concha bullosa as a rare cause of headache differential diagnosis.

Microinvasive Fungal Rhinosinusitis: Proposal of a New Subtype in the Classification

BACKGROUND

Fungal rhinosinusitis (FRS) with mucosal invasion is not classified by the current criteria, and clinical reports on the topic are limited. The aim of this study was to present our 25-year experience on fungal balls with mucosal invasion that do not appear in the FRS classification.

METHODS

Of 1318 patients who underwent endoscopic surgery with paranasal FRS between November 1994 and July 2019, 372 underwent mucosal biopsies. Medical chart and pathology review were performed on 13 patients diagnosed as having fungal balls with mucosal invasion without accompanying tissue invasion.

RESULTS

Histopathologic findings identified all fungi as belonging to the Aspergillus species. In 13 patients, 7 fungal balls were located in the maxillary sinus, 3 in the sphenoid sinus, and 3 in both the maxillary and ethmoid sinuses. The median age at diagnosis was 67 years (interquartile range (IQR): 62-72), and the sex ratio was 1:2 (4 men and 9 women). Five patients had comorbidities-three with diabetes mellitus and two with hematologic malignancy-all of whom received postoperative antifungal therapy. The median duration of antifungal treatment was 13 weeks (IQR: 8-17). No recurrences occurred during the median follow-up period of 30 months (IQR: 22-43).

CONCLUSIONS

Patients who have been clinically diagnosed with a fungal ball and showed mucosal invasion but no vascular invasion, based on pathologic findings after surgery, may need a new FRS classification category, such as microinvasive FRS, and adjuvant antifungal treatment may be needed for immunocompromised patients with microinvasive FRS.

KEY POINTS

Fungal rhinosinusitis with mucosal invasion is different from fungal ball and invasive fungal rhinosinusitis and may be classified in a separate category as microinvasive FRS.

MR Findings of Fungus Ball: Significance of High Signal Intensity on T1-Weighted Images

BACKGROUND

Central dark-signal intensity with high-signal, hypertrophic mucosal wall of paranasal sinuses on T2-weighted images (T2WI) is a characteristic magnetic resonance imaging (MRI) feature of sinonasal fungus ball. However, this finding is usually interpreted as non-fungal chronic sinusitis with central normal sinus air. In addition, T1-weighted images (T1WI) and T2WI are basic sequences of all magnetic resonance (MR) examinations. Therefore, we evaluated the usefulness of T1WI for detecting fungus balls comparing with computed tomography (CT) findings and T2-weighted MRI findings.

METHODS

This retrospective study was approved by the Institutional Review Board of Korea University Guro Hospital. Two reviewers assessed preoperative CT and MR images of 55 patients with pathologically confirmed fungus balls. Reviewers evaluated the presence and patterns of calcifications on CT. Overall signals and the presence and extent of certain signals of fungus balls on MRI were also assessed. The relationship between calcifications and MRI signals was also evaluated.

RESULTS

Of the patients, 89.1% had calcifications on CT. All had dark signal portions with high signal, hypertrophic mucosal walls on T2WI. Most (92.7%) patients showed iso- to hyper-intense overall signals on T1WI and 89.1% had T1-weighted high signal portions on MRI. The presence, patterns, and location of calcifications had no significant correlation with T1-weighted high-signal intensity portion.

CONCLUSION

Fungus ball can be suggested by the presence of the hyper-signal intensity portions in the fungal mass on T1WI in conjunction with dark-signal lesions surrounded by high-signal, hypertrophic mucosal walls in paranasal sinuses on T2WI.

Clinicopathologic characteristics of paranasal sinus fungus ball: retrospective, multicenter study in Korea

PURPOSE

Fungus ball (FB) is the most common type of fungal rhinosinusitis and the prevalence of FB has increased over the past 10 years. The aim of this study was to compare the clinical characteristics of Korean adult patients with FB and chronic rhinosinusitis (CRS) without FB.

METHODS

We retrospectively analyzed data on 1362 patients (147 FB and 1215 CRS) who underwent endoscopic sinus surgery at nine Korean medical centers in 2005, 2010, and 2016. We evaluated the prevalence of FB and compared the clinical characteristics of FB and CRS. Medical records, computed tomography (CT) findings, atopic status, concomitant diseases, tissue, and blood eosinophil count were assessed.

RESULTS

The prevalence of FB was significantly higher in 2016 (15.9%) than in the other years (7.8% in 2005 and 7.5% in 2010). The FB patients were more likely to be female, older, have unilateral disease and less likely to have allergy compared to the CRS patients. The most common main complaint related to CRS and FB was nasal obstruction. CT determined that unilateral disease and maxillary sinus dominancy were common in patients with FB. The incidence of concomitant diseases was much higher in FB, with lower tissue and blood eosinophilia.

CONCLUSION

FB is commonly encountered in older women with the increased prevalence. FB had a different clinical presentation, radiological findings, and prognosis than CRS. Further studies are needed to understand the pathophysiologic mechanisms underlying the development of FB.

Complications of Isolated Fungal Sphenoiditis: Patient Clinical Characteristics

OBJECTIVE

To evaluate the clinical characteristics of patients with complications of isolated fungal sphenoiditis.

MATERIALS AND METHODS

The records of patients diagnosed with isolated fungal sphenoiditis at Songklanagarind Hospital from January 2004 to December 2017 were retrospectively reviewed. Data related to demographics, clinical presentation, underlying disease, type of complication, surgical procedure, and clinical outcome were collected.

RESULTS

Among the 35 participating patients, complications were found at a rate of 40%. The most common complication was visual loss (71.43%). We also compared the clinical characteristics between patients with and without complications via univariate analysis. The enrolled patients consisted of 12 men and 23 women (1:2). The mean age was older in the complications group 64 (41-84) vs. 57.43 (36-81) years, respectively. Underlying diabetes mellitus and complete opacity of the sphenoid sinus were factors that related significantly to the occurrence of complications. After treatment, 35.72% of the participants made a complete recovery; underlying diabetes mellitus was associated with a poor prognosis.

CONCLUSION

This report indicates that practitioners must be careful of complications arising in elderly and female patients with isolated fungal sphenoiditis, who have a complete opacity of the sphenoid sinus and underlying diabetes mellitus.

Clinical Characteristics Other Than Intralesional Hyperdensity May Increase the Preoperative Diagnostic Accuracy of Maxillary Sinus Fungal Ball

Objectives

This study aimed to evaluate the clinical characteristics of maxillary sinus fungus ball (MFB) to increase the preoperative diagnostic accuracy.

Methods

A retrospective review of 247 patients who underwent endoscopic sinus surgery for unilateral maxillary sinusitis from January 2015 to December 2017 at a single institution was performed. Patients with pathologically proven MFB were compared to those with unilateral chronic maxillary sinusitis (CMS). Patient demographics and computed tomography (CT) findings were evaluated. The CT features were categorized as intralesional hyperdensity (calcification), the irregular lobulated protruding lesion (fuzzy appearance), maxillary sinus full haziness without mass effect, maxillary sinus full haziness with mass effect, and others. A regression tree analysis was performed.

Results

In total, 247 patients were analyzed; among them, 179 (72.5%) had MFB and 68 (27.5%) had CMS. MFB showed predominance in older individuals. Among the radiological features, intralesional hyperdensity was most commonly associated with MFB. The presence of a fuzzy appearance or full opacity with mass effect was also associated with MFB. The highest area under the curve was noted with the regression tree analysis based on the model, which included the presence of intralesional hyperdensity, demographic data (age), and presence of fuzzy appearance or maxillary sinus full haziness with mass effect in case of absence of intralesional hyperdensity (0.904).

Conclusion

A simple algorithm to optimize the preoperative diagnosis of MFB was developed. Physicians should be aware of such findings in the management of patients presenting with unilateral CMS.

A fungal ball within a maxillary sinus with dental root canal filler and rare fungal propagules

A fungal ball of a maxillary sinus sometimes includes dental treatment-related foreign material because the sinus is close to the root of the upper teeth. We present a case of right maxillary sinus fungal ball with a gutta-percha point, a dental root canal filler. X-ray analysis of the foreign material in the paraffin section of the fungal ball successfully detected zinc, sulfur, and barium, all of which were constituents of the gutta-percha point. The gutta-percha point might have facilitated the formation of the fungal ball through disruption of the sinus-clearing mechanism. Another interesting histological feature of the fungal ball was the finding of calcium oxalate crystals and non-hyphal fungal elements such as cleistothecia, Hülle cells, and conidial heads. This is the first report of such a combination being found in a specimen of human fungal disease. Although fungal culture was not available in the present case, molecular analysis of the formalin-fixed paraffin-embedded tissue of the fungal ball succeeded in revealing only DNA sequences of Aspergillus nidulans and some other environmental Aspergillus spp.

Fungal Rhinosinusitis: Unravelling the Disease Spectrum

Fungal rhinosinusitis (FRS), once considered a rare disease, has seen a steep rise in incidence in recent times. This global rise in the burden of fungal disease is a consequence of an increment in the population with weakened immune systems. Increased life expectancy with rise in conditions like diabetes mellitus, medical advancements with invasive interventions, use of immunosuppressive drugs and chemo-radiotherapy all lead to unique risk situations. The situation becomes more alarming with the fact that there has been a significant rise in cases in immune-competent hosts with no predisposing factors. FRS represents a wide spectrum of disease ranging from the mild form of superficial colonization, allergic manifestations to life threatening extensive invasive disease. The categorization of disease into acute and chronic and invasive or noninvasive is important factor with implications in disease management and prognosis and this has been emphasized greatly in recent years. Diagnosis of FRS has been a challenge as the presenting clinical signs and symptoms and radiographic manifestations are often nonspecific. Definitive diagnosis requires direct fungi identification and hence culture and microscopic examination remain the gold standard. Availability of advanced and rapid diagnostic techniques is rare in majority of developing nations. Therapeutic dilemmas are another aspect of the management of FRS as in spite of the availability of new antifungal drugs, treatment is often empirical due to non-availability of early diagnosis, rapid disease progression and high costs of antifungal drugs. A description of the different types of FRS, their diagnosis and management has been presented in this review.

Maxillary fungus balls due to Fusarium proliferatum

Fungus ball is the most common form of non-invasive fungal rhinosinusitis. Aspergillusfumigatus (between 44.8% and 75%) and Aspergillusflavus (14%) are the two most common species recovered. However, recent advances in mycological laboratory methods have enhanced the detection and identification of fungi within fungus balls. Fusarium species, sometimes recovered from other forms of fungal rhinosinusitis such as allergic fungal rhinosinusitis or acute invasive fungal rhinosinusitis, are poorly associated with sinonasal fungus ball. Here, we describe two further cases of a fungus ball due to Fusariumproliferatum and provide the first description of this fungal pathogen with a fungus ball of odontogenic origin. These case reports demonstrate that uncommon fungal species such as Fusarium spp. might be underestimated as agents of sinusal cavity fungus ball. Enhanced mycological detection and diagnostic techniques might give rise, in the near future, to the emergence of new or rare fungal species associated with this clinical entity.

Diagnosis of a maxillary sinus fungus ball without intralesional hyperdensity on computed tomography

OBJECTIVES/HYPOTHESIS

Maxillary sinus fungus ball (MSFB) is the most common type of noninvasive fungal rhinosinusitis. Surgical removal of the ball achieves good outcomes. Making a rapid and accurate diagnosis is important to avoid unnecessary medical therapy. Intralesional hyperdensity (IH) on computed tomography (CT) is reportedly a good indicator. The aim of this study was to evaluate the diagnostic features of MSFB without IH on preoperative CT images.

STUDY DESIGN

Retrospective database review.

METHODS

Two hundred fifty-eight patients with histopathological evidence of a sinus fungal ball were retrospectively investigated. Forty-seven of 222 patients with MSFB did not show IH on preoperative CT images and were enrolled in the MSFB group. Forty-one patients with unilateral nonfungal chronic rhinosinusitis were enrolled in a control group. CT features previously reported to have diagnostic significance were evaluated.

RESULTS

Sclerosis of the lateral sinus wall, erosion of the inner sinus wall, and irregular surface of the material were significantly more common in the MSFB group than in the control group. In the subgroup of patients with total opacification in the maxillary sinus, the sensitivity, specificity, and positive and negative predictive values for erosion of the inner sinus wall were more than 90%. In the subgroup with partial opacification, the sensitivity, specificity, and positive predictive value of an irregular surface of the material were more than 80%.

CONCLUSIONS

We have devised an algorithm to help diagnose MSFB without IH on preoperative CT images. Use of this algorithm would improve the diagnostic accuracy and ensure appropriate treatment.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1041-1045, 2019.

Orbital apex syndrome: An unusual complication of invasive mucormycosis

Orbital apex syndrome is a rare manifestation of invasive mucormycosis. We report a case of orbital apex syndrome in a diabetic patient which not only posed a diagnostic challenge but also required a multidisciplinary approach in treatment and management. Prompt imaging followed by early initiation of antimicrobial therapy along with timely surgical intervention were integral in preventing further complications and reducing mortality. However, despite these measures, the patient sustained partial vision loss due to endophthalmitis as a complication.

Nontraumatic emergencies of inflammatory paranasal sinus disease

Inflammatory disease of the paranasal sinuses is extremely common and the course is often innocuous. However, when extrasinus spread of disease occurs life-threatening complications can arise. Intraorbital and intracranial involvement can progress rapidly either by hematogenous spread or in the case of fungal sinusitis via angioinvasion. An understanding of anatomy and appropriate imaging protocols is critical when these complications arise. The knowledge of imaging features of the different disease processes and prompt diagnosis is essential to improve patient outcomes and positively impact patient care.

Fungus Ball of the Maxillary Sinus-Modern Treatment by Osteoplastic Approach and Functional Endoscopic Sinus Surgery

PURPOSE

Functional endoscopic sinus surgery (FESS) is considered standard surgical therapy for fungus ball of the maxillary sinus. However, recent findings have indicated an odontogenic etiology, which requires simultaneous treatment of the dental origin. This study presents the authors' treatment results of fungus ball of the maxillary sinus using a combination of FESS and an endoscopically assisted osteoplastic approach through the anterior wall of the maxillary sinus, enabling simultaneous treatment of the dental origin.

MATERIALS AND METHODS

A cohort of 22 patients with histopathologically confirmed fungus ball of the maxillary sinus was retrospectively analyzed. Clinical records and medical imaging data were reviewed to evaluate the etiology, clinical and radiologic findings, and postoperative outcome.

RESULTS

Only 15 patients presented nonspecific clinical symptoms compatible with chronic unilateral maxillary sinusitis. Computed tomography visualized complete opacity of the maxillary sinus in 11 patients and intralesional hyperdensity in 12 patients. An odontogenic association was verified in 18 patients. Twenty-one patients underwent endoscopically assisted osteoplastic surgery through the anterior maxillary sinus wall. In 12 cases, the assumed persistent odontogenic source was treated simultaneously. Depending on the patency of the ostiomeatal complex, the accompanying chronic sinusitis was treated by FESS.

CONCLUSIONS

The present data support the assumption of an odontogenic etiology of fungus ball of the maxillary sinus. Hence, surgical management requires simultaneous treatment of the fungal mass, the odontogenic origin of the disease, and the accompanying chronic sinusitis. To properly treat fungus ball, the authors present a modern treatment concept, using a minimally invasive endoscopically assisted osteoplastic approach through the anterior maxillary wall, for sufficient and necessary surgical treatment.

Characteristics of Sinus Fungus Ball: A Unique Form of Rhinosinusitis

Objective:

The purpose of this study was to investigate the characteristics of this unique form of rhinosinusitis.

Methods:

Ninety-one patients with sinus fungus balls were evaluated for clinical characteristics. Nasal tissues obtained from 38 patients with sinus fungus ball, along with 26 controls were used for histopathological, cytokines/chemokines, western blotting, and genetic analyses.

Results:

Patients with fungus balls had significantly more females and their age was older. The presentation of fungus ball was predominantly unilateral (97.8%). Thirty-three patients (36.3%) had risk factors for fungal infection. Macrophage and neutrophil dominated cellular infiltration was found in nasal tissues of fungus ball patients. A tendency of reduced tight junction staining (e-cadherin) and protein expression was found. Interleukin 8 (IL8) and granulocyte colony stimulating factor (G-CSF) significantly increased in sinus fungus ball tissue homogenates when compared with those from controls. Higher prevalence of a single single nucleotide polymorphism (SNP) with E-cadherin was found in the patients with fungus ball.

Conclusions:

We found that patients with sinus fungus ball had robust immune responses, allowing recruitment and activation of macrophages and neutrophils. However, patients with sinus fungus ball could have genetic or acquired weakness in immunity. The fungal hyphae were localized and accumulated within single sinus instead of being eradicated by host.

Orbital apex syndrome secondary to aspergilloma masquerading as a paranasal sinus tumor: A case report and literature review

RATIONALE

Orbital apex syndrome is a complex clinical disorder featuring a collection of cranial nerve deficits characterized by impairment of the extraocular muscles, the ophthalmic branch of the trigeminal nerve, and even the optic nerve. Sino-orbital aspergillosis is rare but aggressive infection. Surgical resection accompanied by antifungal medication is advised currently.

PATIENT CONCERNS

We report a 61-year-old woman diagnosed as aspergilloma presenting with the characteristic manifestations and imaging features of orbital apex syndrome.

DIAGNOSES

Paranasal sinus tumor was misdiagnosed initially according to magnetic resonance imaging of the orbit. Finally aspergilloma was diagnosed by pathologic report.

INTERVENTIONS

The anti-fungal medication, voriconazole, was administered immediately. Surgical excision was also done due to the poor response to medical treatment.

OUTCOMES

Postoperative follow-up showed no recurrence of aspergillosis but the vision was lost permanently.

LESSONS

Invasive sino-orbital aspergillosis as an aggressive disease with highly invasive patterns and it may be misdiagnosed as tumors. To achieve better prognosis and survival, clinicians should be aware of this distinct manifestation.

Gauze-Assisted Technique in Endoscopic Removal of Fungus Balls of the Maxillary Sinus

Background

The aim of this study was to establish and evaluate a newly developed gauze-assisted technique in complete removal of fungus balls of the maxillary sinus with usual instruments of endoscopic sinus surgery.

Methods

Fifteen adults with fungus balls of the maxillary sinus were collected. A newly developed surgical technique that involves the replacement of the fungus balls with the gauze strip was applied. The number of course and duration of this procedure were recorded.

Results

The fungal material was removed with less than two courses of this procedure in these patients. The duration of this procedure ranged from 2 to 5 minutes with an average of 4 minutes. Postoperatively, these patients had been followed for 16–50 months with an average of 29 months. Neither recurrence nor complication was noted.

Conclusion

With the excellent results, we strongly suggest this easy and timesaving technique in the management of such patients.

Skull Base Erosion by Sphenoid Fungus Balls: Diagnosis and Endoscopic Treatment

Background

Fungus balls typically are innocuous lesions found in immunocompetent hosts. They are located most commonly in the maxillary sinus but may be life-threatening when found in the sphenoid sinus.

Methods

We review our series of four sphenoid fungus balls with skull base erosion.

Results

Our average patient age was 68.7 years old (56–86 years) with three women and one man. One patient was insulin-dependent diabetic, the other three patients were otherwise healthy. The most common presenting symptoms were headache and dizziness with relatively few sinus-specific complaints. Endoscopy revealed polyps in two of the four patients. Computerized tomography scans revealed thickened osteitic bone in three cases and two of the four computed tomography scans showed microcalcification. All patients had bony erosion over the internal carotid arteries. Additionally, one patient internal carotid artery thrombosis, one patient had erosion of the planum sphenoidale, and a third patient had erosion to the brainstem inferior to the sella turcica. Three patients had magnetic resonance imaging that revealed heterogeneous lesions. Two magnetic resonance images showed hypointense T1 and T2 imaging. The third was isointense on T1 and hypointense on T2. All patients were treated with endoscopic marsupialization and removal of all gross fungal debris without complications. All pathological specimens were diagnostic for fungus balls. One of four cultures was positive for fungus. All patients are asymptomatic at time of last follow-up.

Conclusions

Sphenoid fungus balls present with vague, non-rhinological symptoms, but may have significant local expansion and destruction. These potentially lethal lesions usually can be suspected on preoperative imaging and are best treated with endoscopic removal.

Aspergillus Mycetoma Causing Epiphora and Ipsilateral Facial Pain

Tearing is a frequently encountered chief complaint in an ophthalmologist's office. Certain associated atypical symptoms may warrant further workup. The authors present a case of a patient presenting with painful tearing which elicited further evaluation with CT imaging. This revealed a maxillary sinus fungus ball as the cause for the patient's tearing.

Utility of intraoperative flexible endoscopy in frontal sinus surgery

Background:

Surgical management of the frontal sinus can be challenging. Extensive frontal sinus pneumatization may form a far lateral or supraorbital recess that can be difficult to reach by conventional endoscopic surgical techniques, requiring extended approaches such as the Draf III (or endoscopic modified Lothrop) procedure. Rigid endoscopes may not allow visualization of these lateral limits to ensure full evacuation of the disease process.

Methods:

Here we describe the utility of intraoperative flexible endoscopy in two patients with far lateral frontal sinus disease.

Results:

In both cases, flexible endoscopy allowed confirmation of complete evacuation of pathologic material, thereby obviating more extensive surgical dissection.

Conclusion:

In cases where visualization of the far lateral frontal sinus is inadequate with rigid endoscopes, flexible endoscopy can be used to determine the need for more extensive dissection.

Extrasinonasal infiltrative process associated with a sinonasal fungus ball: does it mean invasive fungal sinusitis?

PURPOSE

Invasive fungal sinusitis (IFS) has rarely been reported to develop from non-IFS. The purpose of this study was to disclose the nature of the extrasinonasal infiltrative process in the presence of a sinonasal fungus ball (FB).

METHODS

We retrospectively reviewed the medical records, computed tomography, magnetic resonance images of 13 patients with sinonasal FB and the extrasinonasal infiltrative process. Based on histology and clinical course, we divided the extrasinonasal infiltrative process into IFS and the nonfungal inflammatory/infectious process (NFIP). The images were analyzed with particular attention to the presence of cervicofacial tissue infarction (CFTI).

RESULTS

Of the 13 patients, IFS was confirmed in only one, while the remaining 12 were diagnosed to have presumed NFIP. One patient with IFS died shortly after diagnosis. In contrast, all 12 patients with presumed NFIP, except one, survived during a mean follow-up of 17 months. FB was located in the maxillary sinus (n=4), sphenoid sinus (n=8), and both sinuses (n=1). Bone defect was found in five patients, of whom four had a defect in the sphenoid sinus. Various sites were involved in the extrasinonasal infiltrative process, including the orbit (n=10), intracranial cavity (n=9), and soft tissues of the face and neck (n=7). CFTI was recognized only in one patient with IFS.

CONCLUSION

In most cases, the extrasinonasal infiltrative process in the presence of sinonasal FB did not seem to be caused by IFS but probably by NFIP. In our study, there were more cases of invasive changes with the sphenoid than with the maxillary FB.

Fungal Rhinosinusitis: A Radiological Review with Intraoperative Correlation

The interaction between fungi and the sinonasal tract results in a range of clinical presentations with a broad spectrum of clinical severity. The most commonly accepted classification system divides fungal rhinosinusitis into invasive and noninvasive subtypes based on histopathological evidence of tissue invasion by fungi. Invasive fungal rhinosinusitis is subdivided into acute invasive and chronic invasive categories. The chronic invasive category includes a subcategory of chronic granulomatous disease. Noninvasive fungal disease includes localized fungal colonization, fungal ball, and allergic fungal rhinosinusitis. Noninvasive disease is simply fungal material (or the products of the inflammatory reaction of the sinus mucosa) that fills the sinuses but does not invade tissue. Bone loss is related to expansion of the sinus(es). Invasive disease causes tissue destruction, such that it expands past the bony confines of the sinuses. It can rapidly spread, causing acute necrosis. Alternatively, there may be slow tissue invasion characterized by symptoms confused with normal sinusitis, but destruction of normal nasal and paranasal structures.

Nasal nitric oxide in unilateral sinus disease

Unilateral sinus disease (USD) can sometimes be difficult to accurately diagnose before surgery. The application of nasal nitric oxide (nNO) for USD diagnosis and its surgical outcome in USD has not been reported in the literature. We prospectively enrolled sixty-six USD patients who underwent endoscopic sinus surgery for fungal rhinosinusitis (n = 19), chronic rhinosinusitis (CRS) without nasal polyps (n = 13), CRS with nasal polyps (n = 12) and sinonasal mass lesions (n = 22). nNO levels were measured preoperatively and at three and six months postoperatively. Correlations between nNO levels and potential clinical parameters, type of disease, disease severity, and disease-related quality of life (QOL) were assessed. Unlike bilateral CRS, in USD, nNO levels did not correlate with disease severity or postoperative QOL improvements. Except for fungus group, there were no differences in nNO levels between lesion and non-lesion sides in all the other groups. nNO levels on both sides were significantly elevated six months postoperatively in all groups. Fungal rhinosinusitis patients had the lowest preoperative nNO levels, and a cutoff of 239.3 ppb had the best sensitivity (79.0%) and specificity (87.2%) for preoperative diagnosis. While preoperative nNO levels cannot serve as an alternative marker for disease severity of USD, they were lower in fungal rhinosinusitis patients than in other USD patients and may be useful for more accurate diagnosis prior to surgery.