fungal sinusitis1

8/13/2019 Fungal Sinusitis1

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Fungal SinusitisDEPARTMENT OF E.N.T


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Fungal Sinusitis

Invasive Fungal Sinusitis.(Fulminantsinusitis)

Chronic invasive Sinusitis.

Fungal Ball.

Saprophytic

Allergic fungal Sinusitis.


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Fungal Sinusitis

Classification Immunologicalstatus

Prognosis Treatment

Invasive compromised Guarded Reversal ofimmunocompramise,Surgery, antifungaltreatment

Chronicinvasive

Normal Good Surgery, antifungalagents

Fungal ball Normal Good Surgery

Saprophytic Normal Good Removal

Allergic FungalSinusitis Atopic Good Surgery , Steroids,antifungal drugs


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Invasive Fungal Sinusitis

Invasive fungal Sinusitis is almostconfined to patients with altered hostdefenses, such as

Diabetic patients. Undergoing transplantation ( Bone

marrow, liver, Kidney and so on)

Leukemia. Primary or acquired immunodeficiency.


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Fungal Species

Mucormycosis : Order Mucorales

Class Zygomycetes

species Rhizopusoryzae

Aspergillosis Aspergillus flavus

Aspergillus fumigatus


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Invasive fungal Sinusitis

Mucormycosis

Obliterative invasion.

Aspergillosis

angioinvasive


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Clinical Features

Fever.

Symptoms of sinusitis ,

Orbital swelling,

Facial pain and nasal congestion

Anterior rhinoscopy, necrosis of nasalmucosa and edema.

Anesthesia of nasal mucosa and cheek. There may be invasion through hard

palate.


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Diagnosis

DNE

C.T. Scan.

M.R.I

Biopsy with special fungal stains. Culture with special fungal stains such as

calcoflour white.


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C.T.Scan

Metallic density area isseen in the maxillaryantrum . This is dueto crystallization of

calcium salts withinthe mycotic mass.


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C.T.SCAN

High-and low-densityareas are noticedinside the leftmaxillary sinus. This

gives a high index ofsuspicion for a fungalinfection.


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M.R.I

MRI findings are related to inspissated secretions.

A T1-weighted image through the opacified sinus showsmucosal thickening with isointense signal that increasedwith 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 infectionand dehydrated inspissated mucous, calcifications, and iron

salt deposition


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PAS

PAS (periodic acid-Schiff) stain of sinuscontent showsseptated hyphae

branching at 45degrees characteristicof aspergillosis.


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Mucor


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Aspergillus


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Treatment

Reversal of underlying predisposingconditions.

Systemic antifungal therapy.

Surgical debridement.


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Antifungal therapy

Systemic amphotericin B at I.V dosage of0.8 to 1.5 mg/kg/day to total dose of upto 3g.

Nephrotoxicity Fever, chills, nausea and hypotention.

These complications can be reduced or

eliminated with the use amphotericine Blipid complex.


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Other drugs

Itraconozole (Argillosis )

Voriconozole.


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Chronic Invasive fungal Sinusitis

Aspergillus flavus.

Aspergillus fumigatus.

Immunocompetent patients present with

pain less proptosis.

Indolent fungal sinusitis, with extention toorbit or palate


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Diagnosis

Biopsy .

Histologic picture is a granuloma in whichgiant cells contain hyphae.


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Complications

Blindness.

Cerebral extention.


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Treatment

Surgical exenteration.

Systemic anti fungal therapy.


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Fungus Balls

Fungus balls (Mycetoma) are common andgrow in the wet , moist cavities of thepara nasal sinuses, irrespective of the

immunological status of the host. Asymptomatic.

Cause symptoms indistinguishable fromchronic sinusitis.


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Fungal species

A.flavus.

A.fumigatus.

Alternaria and mucor.


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Histology

Tangled hyphae charectoristic of fungusballs


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Treatment

Conservative surgical removal byendoscopic surgical techniques.


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Saprophytic Fungal infection

Saprophytic Fungal infections occur whenubiquitous fungal spores land andgerminate on mucus crusts which fail to

clear the sinonasal cavity. Commonly seen after sinonasal surgery.

Treatment removal of crust


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Allergic Fungal sinusitis

Patients with AFS are atopic with nasalpolyps.

One third may have asthma.


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Fungal species

The majority of fungal species aredematiaceous (darkly pigmented).

Alternaria.

Bipolaris Curvularia

Aspergillus


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Bony erosiosn is common on sinus C.TScan.

Inspissated mucus causes heterogeneous

soft tissue density. Diagnosis is made histopathologically by

noting allergic mucin characterized byinflammatory cells,

Eosinophills and

Charcot leyden crystals ( a by product ofeosinophil degranulation)


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In this allergic mucin hyphal elements arebest appreciated with fungal stains.


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Treatment

Conservative non mutilating removal ofpolyps and inspissated allergic mucin byFESS.

Systemic steroids prednisone 60mg/dayfor several days and tapered off over 2-3weeks.

Endoscopic debridement.


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Immunology

Increased IgE and IgG to the specificfungus.

Increase in Serum IgE level.

As allergic fungal sinusitis causes increasein IgG and IgE,

Immunotherapy is helpful as it induces a

specific IgG blocking antibody


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Cavernous sinuses The cavernous sinuses are

irregularly shaped,trabeculated cavitieslocated at the base of theskull.

The cavernous sinuses are

the most centrally locatedof the dural sinuses and lieon either side of the sellaturcica.

These sinuses are justlateral and superior to the

sphenoid sinus and areimmediately posterior tothe optic chiasma,

.


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The cavernous sinuses

The cavernous sinusesreceive venous bloodfrom the facial veins(via the superior andinferior ophthalmic

veins) the sphenoidand middle cerebralveins.

The cavernous sinusesempty via the superior

petrosal sinuses, intothe inferior petrosalsinuses, then into theinternal jugular veinsand the sigmoidsinuses

.


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The cavernous sinuses

This complex web ofveins contains novalves;

Blood can flow in anydirection depending

on the prevailingpressure gradients.

Since the cavernoussinuses receive bloodvia this distribution,

infections of the faceincluding the nose,tonsils, and orbitscan spread easily bythis route


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Cavernous sinus

The internal carotid arterywith its surroundingsympathetic plexus passesthrough the cavernoussinus.

The third, fourth, and sixthcranial nerves are attachedto the lateral wall of thesinus. The ophthalmic andmaxillary divisions of thefifth cranial nerve are

embedded in the wall,


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Cavernous sinus thrombosis

Cavernous sinus thrombosis(CST) is the formation of a blood clotwithin the cavernous sinus,

The cause is usually from aspreading infection in the sinuses,ears, or teeth.

Staphylococcus aureusandStreptococcus
http://en.wikipedia.org/wiki/Cavernous_sinushttp://en.wikipedia.org/wiki/Staphylococcus_aureushttp://en.wikipedia.org/wiki/Streptococcushttp://en.wikipedia.org/wiki/Streptococcushttp://en.wikipedia.org/wiki/Staphylococcus_aureushttp://en.wikipedia.org/wiki/Cavernous_sinus


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Cavernous sinus thrombosis

Cavernous sinus thrombosis causes

Decrease or loss of vision,

Drooping or bulging eyes,

Headaches, and paralysis of the cranialnerveswhich course through thecavernous sinus.

This infection is life-threatening and

requires immediate treatment, whichincludes antibioticsand

Sometimes surgical drainage
http://en.wikipedia.org/wiki/Cranial_nervehttp://en.wikipedia.org/wiki/Cranial_nervehttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Cranial_nervehttp://en.wikipedia.org/wiki/Cranial_nerve


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Cavernous Sinus Thrombosis

This is one of the complication of infectionof the paranasal sinuses.

Ethmoid

Sphenoid. Frontal Sinus.

Orbital complications from these sinus

infections can cause thrombophlebitis ofthe cavernous sinus.


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Other causes

Source Disease Route

Nose and dangerarea of face

Furuncle andseptal abscess

Pharyngeal plexus

Ethmoid sinuses Orbital cellulitis and

abscess

Ophthalmic veins

Sphenoid andfrontal sinus

Sinusitis.Sinusitis andosteomyelitis offrontal bone

DirectSupraorbital andophthalmic vein

Orbit Cellulitis and

abscess

Ophthalmic veins

Upper lid Abscess Angular andophthalmic veinns

Pharynx Acute tonsilitis orPeritonsillar abscess

Pharyngeal plexus

Ear Petrositis Petrosal venoussinus


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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 totalophthalmoplegia.

Pupil gets dilated and fixed.


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Clinical features

Optic disc is congested and edematouscausing diminution of vision.

Sensation in the distribution of Vi

(ophtolmic branch of CNV) is diminished.


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Diagnosis

C.S.F is normal

C.T.Scan


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Angiogram

Findings may includedeformity of theinternal carotid arterywithin the cavernous

sinus, and an obvioussignal hyperintensitywithin thrombosedvascular sinuses on all

pulse sequences.
http://en.wikipedia.org/wiki/Cerebral_angiographyhttp://en.wikipedia.org/wiki/Cerebral_angiography


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C.T.Scan

Sinus films are helpful inthe diagnosis of sphenoidsinusitis.

Opacification, sclerosis,and air-fluid levels are

typical findings. Contrast-enhanced CT

scanmay revealunderlying sinusitis,thickening of the superiorophthalmic vein, and

irregular filling defectswithin the cavernoussinus;

however, findings may benormal early in the diseasecourse.
http://en.wikipedia.org/wiki/CT_scanhttp://en.wikipedia.org/wiki/CT_scanhttp://en.wikipedia.org/wiki/Sinusitishttp://en.wikipedia.org/wiki/Sinusitishttp://en.wikipedia.org/wiki/CT_scanhttp://en.wikipedia.org/wiki/CT_scan


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C.T.Scan


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Differential Diagnosis

Source Orbital cellulitis Cavernous sinusThrombosis

Source Commonly ethmoid

sinus

Nose, sinuses,

orbit, ear, andpharynx.

onset Slow; starts withedema of eye lidsthe inner canthuschemosis--proptosis

Abrupt with highfever and chillswith signs oftoxemia edema ofeye lids, chemosisand proptosis

Cranial nervesinvolvement

Involvedconcurrently withcompleteophthalmoplagia

Involvedindividually andsequentially.

Laterality Often involves oneeye Involves both eyes


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Treatment

I.V. antibiotics, after taking blood forculture,

Treatment of focus of infection.

Drainage of infected ethmoid andsphenoid sinus.

Anti coagulants

fungal sinusitis1

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