Sphenoid sinus fungal balls

Clinical Characteristics of Sphenoid Sinus Fungus Ball: A Nine-year Retrospective Study of 77 Cases

OBJECTIVE

This study aimed to investigate the clinical characteristics of sphenoid sinus fungus ball (SSFB) to help increase the accuracy of diagnosis and efficiency of treatment.

METHODS

We retrospectively analyzed the data of 77 patients who were histopathologically diagnosed with SSFB.

RESULTS

The mean age of SSFB patients was 52.4 years (range 25-84), and 47 patients (61.0%) were female. Compared to age-matched and sex-matched chronic rhinosinusitis (CRS) patients, headache was more common in SSFB patients (79.2%; p < 0.0001). SSFB patients also had higher prevalence of diabetes than CRS (p = 0.0420). The features of computed tomography (CT) were sphenoid sinus opacification (100%), sclerosis (93.5%), calcification (76.6%), and bone erosion (41.6%). Functional endoscopic sinus surgery (FESS) was the best treatment option, and the trans-ethmoid (n = 64, 83.1%) was the most commonly used approach. No one experienced a recurrence of SSFB in 44 successfully contacted patients. Six months after FESS, 91.0% of patients (40/44) established proper drainage in the sphenoid sinus. The recovery rates for headache and nasal symptoms were 91.7% (33/36) and 77.8% (7/9) respectively.

CONCLUSION

SSFB is more prevalent in older women and usually presents as unilateral headache. Diabetes is a potential risk factor for SSFB. CT findings provide evidence for diagnosis and suggestions for surgical approaches. FESS is the optimal treatment for SSFB. After FESS, most patients had good prognosis with no recurrence of SSFB. However, regular endoscopic follow-up is required due to the possibility of the postoperative closure of sphenoid ostium.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3292-3298, 2023.

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.

Characterization of fungus ball CT-hyperdensities within maxillary and sphenoid sinuses

OBJECTIVES

CT-scan hyperdensities (HD) are described in more than 60% of all paranasal sinus fungus ball (FB) cases. Two types can be distinguished according to their density: calcium and metal types. We aimed to establish the prevalence and density of the HD observed in sphenoid and maxillary sinus FB and their relation to dental factors.

METHODS

This retrospective study included 64 patients operated in a tertiary referral center for unilateral maxillary or sphenoid FB diagnosed by histology or mycology. Pre-operative CT scans were analyzed by three independent observers (two ENT and one radiologist).

RESULTS

There were 45 maxillary FB and 19 sphenoid FB. 63 FB showed HD. Metal-type HD were observed in 28 maxillary FB but not in sphenoid sinuses. Among maxillary FB, the prevalence of endodontic treatment was significantly more significant on the FB side than on the healthy side (p = 0.02). The prevalence of endodontic treatment on the pathological side was more significant in the metal-type group than in the group without metal-type HD (p = 0.01). Isolated calcium-type HD were evidenced in 17 maxillary FB and 18 sphenoid FB (p = 0.019).

CONCLUSION

This study highlights the existence of two different types of HD in FBs of the paranasal sinuses with an association between metal-type HD and endodontic treatments.

Surgical treatment of isolated sphenoid sinusitis - A case series and review of literature

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Isolated sphenoid opacification is a rare pathology that is increasingly being described and it represents 1–2% of sinus infections.

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The most frequent symptom associated with isolated sphenoid sinusitis is intractable headache.

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Isolated sphenoid sinusitis is usually treated surgically and endoscopic transnasal sphenoidectomy is the preferred surgical technique.

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Highly inflammatory diseases such as fungal infections may be associated with an increased risk of re-ossification of the sphenoid ostium following sphenoidectomy.

Introduction

Isolated sphenoid opacification is a rare pathology. Unlike other sinusitis, the treatment is most often surgical. Only few studies reporting the recurrence rates with long-term follow-ups are available in the literature. In our experience, isolated sphenoid sinusitis tends to have a significant recurrence rate after a first surgical intervention. This study aims to describe our experience with patients operated for isolated sphenoid sinusitis and to compare our reoperation and complication rates with those reported in the literature.

Methods

We conducted an electronic chart review of patients operated at the CHU de Québec between 2007 and 2018 for isolated sphenoid sinusitis.

Results

29 patients were analyzed. All patients had a sphenoidectomy with a transnasal approach. The reoperation rate was 103% (3/29) and the mean recurrence time was 15 (9–26) months. Among the patients reoperated, 2 patients had a fungus ball and one had a mucocele. Both patients with fungal balls had reossification of their sphenoidal ostium whereas the patient with the mucocele rather had a mucosal closure. No patient encountered any serious post-operative complication. Median duration of follow-up was 44 months (IQR: 25–68) for the 29 patients analyzed in our study.

Conclusion

Reoperation rates reported in the literature are probably underestimated. Our series emphasizes the importance of long-term follow-up for these pathologies. Highly inflammatory and chronic conditions such as fungal diseases could be linked to an increase in the occurrence of relapses.

Headache Secondary to Isolated Sphenoid Sinus Fungus Ball: Retrospective Analysis of 6 Cases First Diagnosed in the Neurology Department

Fungal sphenoid sinusitis is easily misdiagnosed in clinic, particularly for patients with normal immunological status. Due to the anatomic characteristics of sphenoid sinus, patients presented with various nonspecific symptoms and complications. Headache is the most common presentation, but location of headache is not fixed. We intended to analyze 6 cases of headache secondary to the isolated sphenoid sinus fungus ball (SSFB) which were first diagnosed in the Neurology Department. There was significant female predominance with mean ages of 55 years. They had repeatedly headache history from months to years. The headache was unilateral and usually on the side of lesions. Medication of pain relievers worked well in the beginning of SSFB, but not in the late stage of disease. Notably, all patients did not present positive nervous systemic signs. A preoperative computed tomography (CT) scan or magnetic resonance imaging (MRI) demonstrated the inflammation in sphenoid sinus. Some cases showed calcification in soft tissue or bone lesions of sinus wall. All of 6 patients undertook transnasal endoscopic sphenoidotomy without antifungal therapy after operation. Characteristic fungus ball (FB) was detected after histopathological examination. No headache recurrence was found after average 15.5 months follow-up. Our results suggested that transnasal endoscopic sphenoidotomy is the treatment of choice to remove the FB in sphenoid sinus with a low rate of morbidity and recurrence.

Deadly Sphenoid Fungus-Isolated Sphenoid Invasive Fungal Rhinosinusitis: A Case Report

INTRODUCTION

Acute invasive fungal rhinosinusitis (AIFRS) is a potentially fatal infection, usually affecting immunocompromised patients. Isolated sphenoid sinus involvement is rare and has been reported in only a few cases. We discuss the clinical characteristics, histopathologic features, and differential diagnosis of AIFRS of the sphenoid sinus.

CASE PRESENTATION

A 57-year-old man with a history of refractory non-Hodgkin lymphoma and neutropenia presented with a 1-week duration of left-sided headache and ipsilateral cheek paresthesia. Nasal endoscopy showed mucoid drainage from the sphenoethmoidal recess. Magnetic resonance imaging demonstrated left sphenoid mucosal thickening and enhancement along the adjacent skull base. The patient underwent endoscopic sinus surgery with extended sphenoidotomy and débridement. The lateral wall and recess of the left sphenoid sinus demonstrated pale mucosa and fungal debris. Pathologic analysis demonstrated necrotic tissue and fungal hyphae with angioinvasion. Microbiology studies isolated Aspergillus fumigatus. The right maxillary sinus contained a synchronous fungal ball, which was removed during surgery; there was no evidence of tissue necrosis or invasive fungus in the maxillary sinus. He was treated with long-term voriconazole therapy, and 6-month follow-up showed disease resolution.

DISCUSSION

AIFRS should be considered in the differential diagnosis of immunocompromised patients with nonspecific sinonasal symptoms. Usually, AIFRS is diffuse with multiple sinus involvement; however, isolated sphenoid AIFRS can occur. This is one of the few cases of AIFRS demonstrating isolated sphenoid involvement and is thought to be the first case showing a synchronous noninvasive fungal ball of another sinus cavity. Prompt recognition and surgical treatment may be curative and lifesaving.

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.

Isolated sphenoid sinus fungus ball: a retrospective study conducted at a tertiary care referral center in Korea

Fungus ball (FB) is the most common form of extramucosal fungal rhinosinusitis involving one or more paranasal sinuses. The sphenoid sinus is an uncommon site of this disease. Here, we present our 20-year experience of managing isolated sphenoid sinus FB (SSFB). We retrospectively reviewed a series of 47 cases of isolated SSFB encountered between 1996 and 2015 with reference to the chronological incidence, demographics, clinical features, radiological findings, treatment modalities, and outcome. Recently, the number of patients with isolated SSFB has increased markedly. The mean age of the patients in this study was 63.1 years (range 26-84 years), and there was significant female predominance. The most common symptom was headache (72.3%), which was localised in various regions. On the other hand, nasal symptoms presented at a relatively low rate. On computed tomography, the most common findings were total opacification, calcification, and sclerosis of the bony walls. There was no significant difference in the presence of SSFB between the ipsilateral and contralateral sides of the nasal septal deviation and concha bullosa. Magnetic resonance imaging demonstrated an isointensity on T1-weighted images and marked hypointensity on T2-weighted images. Treatment consisted of endonasal endoscopic sphenoidotomy with complete removal of the FB. The prognosis was good, with no recurrence after a mean follow-up of 13.2 months. Isolated SSFB is a rare disease, but its prevalence is increasing. Although the clinical presentation is usually vague and nonspecific, SSFB should be considered in patients with unexplained headache, especially in elderly women. Endoscopic sphenoidotomy is a reliable treatment with low morbidity and recurrence rates.

Skull base erosion and associated complications in sphenoid sinus fungal balls

BACKGROUND

Sphenoid sinus fungal balls (SSFB) are rare entities that can result in serious orbital and intracranial complications. There are few published reports of complications that result from SSFB.

OBJECTIVE

To review the incidence of skull base erosion and orbital or intracranial complications in patients who present with SSFB.

METHODS

A retrospective review was performed of all the patients with SSFB who were treated at the Massachusetts Eye and Ear Infirmary from 2006 to 2014. Presenting clinical data, radiology, operative reports, pathology, and postoperative course were reviewed.

RESULTS

Forty-three patients with SSFB were identified. Demographic data were compared between patients with (39.5%) and those without (61.5%) skull base erosion. Two patients underwent emergent surgery for acute complications of SSFB (one patient with blindness, one patient who had a seizure). Both patients with acute complications had evidence of skull base erosion, whereas no patients with an intact skull base developed an orbital or intracranial complication (p = 0.15). All the patients were surgically managed via an endoscopic approach.

CONCLUSION

SSFBs are rare but may cause significant skull base erosion and potentially severe orbital and intracranial complications if not treated appropriately. Endoscopic sphenoidotomy is effective in treating SSFB and should be performed emergently in patients who presented with associated complications.

Sphenoid sinus aspergilloma in trans-sphenoidal surgery for pituitary adenomas

BACKGROUND

Simultaneous appearance of sphenoid sinus aspergilloma and pituitary adenoma is a very rare finding.

METHODS

Retrospective analysis of patients with sellar and sphenoid sinus mass lesions who underwent trans-sphenoidal surgery was performed. Demographic data, medical history, predisposing factors, clinical picture, neurological status and radiological findings were reviewed. All patients underwent a trans-sphenoidal microsurgical treatment, and acquired specimens underwent both histopathological and microbiological analysis.

RESULTS

Sphenoid sinus aspergilloma was encountered in seven patients. Three patients had an isolated sphenoid sinus aspergilloma and four patients with pituitary macroadenoma had a sphenoid aspergilloma as an incidental finding.

CONCLUSIONS

Sphenoid sinus aspergilloma can be found during trans-sphenoidal surgery for pituitary adenomas. Sphenoid sinus extirpation followed by adenomectomy is the treatment of choice unless invasive aspergilloma is encountered requiring additional antifungal therapy.

Sphenoid sinus fungus ball by filaments of actinomycetes and Aspergillus fumigatus

We present a case of sphenoid sinus fungus ball caused by Aspergillus fumigatus associated with actinomycosis. This case represents the first known reported infection caused by this rare association.

Relationship between biofilms and clinical features in patients with sinus fungal ball

The presence of bacterial biofilms (BBF) and fungal biofilms (FBF) is associated with greater disease severity in chronic rhinosinusitis. However, researches on biofilms in fungal rhinosinusitis are rare. This study investigated the relationship between biofilms and clinical features in patients with sinus fungal ball (SFB). Sixty-four SFB patients undergoing endoscopic sinus surgery and 21 controls were enrolled in this study. Mucosal samples from nasal sinuses were collected for biofilm detection under confocal scanning laser microscopy (CSLM). The general clinical data, Lund-Mackay computed tomography (CT) score, Lund-Kennedy endoscopy score, Global Osteitis Scoring Scale (GOSS) score, Sinonasal Outcome Test (SNOT)-22 score and visual analog scale (VAS) score were recorded. Associations between these parameters and biofilms were assessed. Under CSLM, the positive rates of BBF and FBF were 45.3 % (29/64) and 21.9 % (14/64), respectively in the SFB group but none in controls. When sub-classified according to biofilm status, the BBF-positive subgroup had significantly higher Lund-Mackay score and GOSS score than the BBF-negative one, but there were no differences in demographic characteristics, health-related quality-of-life and endoscopic inflammatory severity. BBF and FBF coexisted on the sinus mucosa of the patients with SFB. BBF was associated with more severe disease, but the distribution of FBF did not affect the severity of SFB.

Characterization of lignocellulolytic activities from a moderate halophile strain of Aspergillus caesiellus isolated from a sugarcane bagasse fermentation

A moderate halophile and thermotolerant fungal strain was isolated from a sugarcane bagasse fermentation in the presence of 2 M NaCl that was set in the laboratory. This strain was identified by polyphasic criteria as Aspergillus caesiellus. The fungus showed an optimal growth rate in media containing 1 M NaCl at 28°C and could grow in media added with up to 2 M NaCl. This strain was able to grow at 37 and 42°C, with or without NaCl. A. caesiellus H1 produced cellulases, xylanases, manganese peroxidase (MnP) and esterases. No laccase activity was detected in the conditions we tested. The cellulase activity was thermostable, halostable, and no differential expression of cellulases was observed in media with different salt concentrations. However, differential band patterns for cellulase and xylanase activities were detected in zymograms when the fungus was grown in different lignocellulosic substrates such as wheat straw, maize stover, agave fibres, sugarcane bagasse and sawdust. Optimal temperature and pH were similar to other cellulases previously described. These results support the potential of this fungus to degrade lignocellulosic materials and its possible use in biotechnological applications.

Mini-nasoseptal flap for recalcitrant sphenoid sinusitis

BACKGROUND

Recalcitrant sphenoid sinusitis occurs in 27% of patients undergoing revision functional endoscopic sinus surgery. One of the main causes of disease recurrence in the sphenoid is cicatricial scarring of the ostium. Highly inflammatory lesions such as fungal balls or chronic mucoceles can predispose patients to restenosis. We present a novel use of a modified nasoseptal flap to cover exposed bone after sphenoid wide sinusotomy to prevent restenosis and expedite healing.

METHODS

A case series was performed.

RESULTS

The mini-nasoseptal flap was successful in preventing sphenoid ostium restenosis in nine patients undergoing endoscopic sinus surgery for highly inflammatory sphenoid sinus pathology with a mean postoperative follow-up of 8.4 months (range, 2-21 months). Patients had a mean of 2.3 prior sinus surgeries (range, 0-7 surgeries). Most common indications for the flap in this series included long-standing fungal sinusitis or fungal balls (n = 6) with or without significant sphenoid wall osteoneogenesis (n = 6). There were no significant side effects related to flap harvest or inset.

CONCLUSION

The mini-nasoseptal flap decreases the risk of restenosis after sphenoid sinusotomy by preventing circumferential cicatricial scarring and offers an effective surgical option on the spectrum of sphenoid surgical interventions in select patients.

The role of fungi in diseases of the nose and sinuses

BACKGROUND

Human exposure to fungal elements is inevitable, with normal respiration routinely depositing fungal hyphae within the nose and paranasal sinuses. Fungal species can cause sinonasal disease, with clinical outcomes ranging from mild symptoms to intracranial invasion and death. There has been much debate regarding the precise role fungal species play in sinonasal disease and optimal treatment strategies.

METHODS

A literature review of fungal diseases of the nose and sinuses was conducted.

RESULTS

Presentation, diagnosis, and current management strategies of each recognized form of fungal rhinosinusitis was reviewed.

CONCLUSION

Each form of fungal rhinosinusitis has a characteristic presentation and clinical course, with the immune status of the host playing a critical pathophysiological role. Accurate diagnosis and targeted treatment strategies are necessary to achieve optimal outcomes.

Sphenoid Sinus Fungus Ball: Our Experience

Background

Fungal rhinosinusitis is a common disease of the paranasal sinuses. The fungus ball (FB) is defined as an extramucosal mycotic proliferation that fills one or more paranasal sinuses. Sphenoid sinus is an uncommon localization of this disease, as reported in the literature. This study describes our experience in the diagnosis and treatment of sphenoid sinus FB (SSFB), with a particular focus on the surgical approach to the sphenoid sinus.

Methods

We retrospectively analyzed the clinical records of patients affected by FB of the sphenoid sinus, who underwent endoscopic sinus surgery (ESS) in our institutions between 1995 and 2009. We described the surgical technique, the methods of mycological and histopathological evaluation, as well as the perioperative and postoperative management.

Results

From 1995 to 2009, 226 patients affected by sinonasal FB underwent ESS in our institutions. A sphenoid localization was found in 56 patients (24.78%; mean age, 62 years). Cephalea was the most common symptom, and 14.3% of patients complained of ocular symptoms. We performed a direct paraseptal sphenoidotomy in 31 patients (55.4%) and a transethmoidal sphenoidotomy in 25 patients (44.6%). Histology unveiled fungal hyphae with absent mucosal invasion in all cases. Cultural results revealed positivity for mycotic colonization in 26 cases (46.4%, most commonly Aspergillus fumigatus). Follow-up ranged from 12 to 181 months with a mean of 70.7 months.

Conclusion

The description of our experience in the diagnosis and treatment of SSFB underlines the importance of a precise diagnostic pathway in case of sphenoidal disease. Nowadays, in our opinion, the paraseptal direct sphenoidotomy represents the less invasive, fastest and most anatomically conservative approach to the sphenoid sinus in case of SSFB.

IFI = invasive fungal infections. What is that? A misnomer, because a non-invasive fungal infection does not exist!

In principle, one has to differentiate between a mere colonization and an invasive fungal infection (IFI) with quite different clinical manifestations and consequences. If the term invasive were used in its proper sense (expressis verbis), all fungal infections could be called invasive, even a fungal keratitis or an infection of the hairs by dermatophytes. In general, however, the term IFI is used only to characterize systemic, generalized, deep-seated, visceral and severe, life-threatening fungal infections, in contrast to superficial, local, benign, self-limiting fungal diseases. The term IFI as used generally is thus misleading, confusing, and not at all helpful to correctly differentiate mild, moderate, and severe fungal infections.

Sphenoid Fungus Balls: Clinical Presentation and Long-Term Follow-Up in 24 Patients

Fungus balls are a non-invasive form of fungal infection involving the maxillary sinus in most cases. Sphenoid sinus fungus balls (SSFB) are rare and their clinical presentation is not well described. We intended to define the clinical presentation of sphenoid fungus balls, and retrospectively reviewed 24 cases of SSFB seen at our institution over a 10-year period, identified through pathological reports. Presenting symptoms were separated into three groups: headache, rhinological and asymptomatic. Headaches were subdivided into acute and chronic, unilateral and diffuse. Radiological clues leading to diagnosis were reviewed. Prognosis was determined from medical files or by phone calls. Sixty-seven per cent of patients were female. The mean age at presentation was 65 years. Sixty-two per cent presented with headache, 36% unilateral, mainly in the first trigeminal branch territory. Rhinological symptoms were seen in 21%. In 16% of patients the SSFB was asymptomatic and found during routine tests. SSFB, even if noninvasive, did lead to recurrent bacterial infections and central nervous system complications in three patients. Of 15 patients presenting with headache, 10 were significantly improved post surgery. The prognosis is good, with no recurrence of fungal infection after a main follow-up of 2.3 years. Our study underlines that SSFB present with headaches, often unilateral and in the fronto-orbital region. Proper imaging of the sphenoid sinus is useful in patients with unexplained headache. The neurologist has to be aware of radiological clues suggesting fungal sinus infection, since surgery is the main treatment, with good prognosis and frequent resolution of headaches.