Fungal granuloma of the sphenoid sinus and clivus in a patient presenting with cranial nerve III paresis: case report rand review of the literature

Orbital apex syndrome due to invasive aspergillosis in an immunocompetent patient

Infection is a rare cause of orbital apex syndrome (OAS) and most commonly occurs in immunocompromised hosts. We report a case of OAS in an elderly immunocompetent female due to invasive aspergillosis and Staphylococcus aureus co-infection. The patient required both surgical debridement and prolonged courses of antibiotic and antifungal therapy. Invasive fungal disease must be considered in cases of OAS, even in patients without classic risk factors.

Invasive sphenoid sinus aspergillosis mimicking sellar tumor: a report of 4 cases and systematic literature review

Background

Invasive sphenoid sinus aspergillosis is a rare but life-threatening condition usually found in immunocompromised patients. When involving cavernous sinus and surrounding structures, patients are frequently misdiagnosed with a neoplasm or sellar abscess. Timely diagnosis and intervention are crucial to patients’ outcomes. The objective of this study is to review cases of invasive sphenoid sinus aspergillosis to describe disease manifestations, imaging features, treatment, and outcome.

Case presentation

We describe four patients with invasive sphenoid sinus aspergillosis misdiagnosed as sellar tumors preoperatively. The mass was completely removed in three patients and partially removed in one patient microscopically. Pathological examinations confirmed Aspergillus in all cases. All four patients received anti-fungal agents postoperatively. There was no recurrence at the time of each patient’s follow-up date. One patient with complete resection was lost to follow-up while the other three patients’ neurologic function improved. Additionally, we performed a systematic review regarding invasive sphenoid sinus aspergillosis of existing English literature.

Conclusion

With regard to clinical symptoms, headache, vision impairment, and ophthalmoplegia were observed in over half of the patients in the literature. A sellar mass with bone destruction on CT and involvement of cavernous sinus is highly suggestive of invasive fungal sphenoid sinusitis. Immediate surgical removal of the lesion is recommended for invasive sphenoid sinus aspergillosis to preserve nerve function and increase the likelihood of survival.

Secondary headache due to aspergillus sellar abscess simulating a pituitary neoplasm: case report and review of literature

Fungal sellar abscess is rare. A 42-year-old man was admitted with 2-month headache characterized by right peri-orbital pain. An intrasellar mass was found to be simulated a pituitary neoplasm after magnetic resonance imaging examination, and operated on via an endoscopic trans-sphenoidal approach. Milk-like pus and a mass of ash black mixed and necrotic material were found and removed. Histopathology revealed numerous aspergillus hyphae. Itraconazole was given on a dosage of 200 mg twice a day orally for 6 weeks. No recurrence was observed during follow-up. Complete surgical resection through endoscopic trans-sphenoidal approach combined with systemic anti-fungal therapy, should be considered as the optimal treatment.

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.

Neuro-ophthalmic manifestations of fungal disease associated with posthurricane environment

BACKGROUND

Allergic fungal sinusitis (AFS) is thought to represent an immunologic response to exposure to dematiaceous fungi. These fungi are known to cause disease more frequently in hot and humid climates and seasons.

METHODS

Three patients presented with unusual manifestations of fungal disease after exposure to environments recently affected by hurricanes.

RESULTS

Two patients had AFS, 1 with gradual painless visual loss from an AFS mass extending into the suprasellar region and 1 with orbital apex syndrome. Another patient had invasive fungal disease and developed orbital apex syndrome.

CONCLUSIONS

These cases underscore the importance of clinical recognition of fungal disease in patients with sinus, orbital, or skull base involvement as well as its potential for causing permanent visual loss. This report suggests a potential association between fungal disease and tropical storm exposure.

Fatal case of cerebral aspergillosis : a case report and literature review

Cerebral aspergillosis is rare and usually misdiagnosed because its presentation is similar to that of a tumor. The correct diagnosis is usually made intra-operatively. Cerebral abscess with fungal infection is extremely rare and few cases have been reported, but it carries a poor prognosis.

A 73 year-old man presented with decreased visual acuity and paresis of the right cranial nerve III. Magnetic resonance imaging (MRI) revealed a mass in the right cavernous sinus, extened to the anterior crainial fossa and the superior orbital fissure. During surgery, a well encapsulated pus pocket was found, and histopathological examination of the mass resulted in the diagnosis of aspergillosis. Despite appropriate anti-fungal treatment, the patient eventually died from fatal cerebral ischemic change and severe brain swelling.

The correct diagnosis of cerebral aspergillosis can only be achieved by histopathological examination because clinical and radiological findings including MRI are not specific. Surgical intervention and antifungal therapy should be considered the optimal treatment. Early diagnosis and aggressive antifungal treatment provide good results.

Aspergillus osteomyelitis of the lumbar spine complicated with orbital apex syndrome: A potential role of the Batson's plexus in disease propagation

We report a rare case of orbital apex syndrome following epidural steroid injections of the lumbar spine in an immunocompetent individual with osteomyelitis and discitis caused by Aspergillus fumigatus. We suspect that the craniospinal venous system, also known as the Batson's plexus, was the main route for steroid-facilitated disease propagation from the spine to intracranial structures.

[Fungal infections of the paranasal sinuses treated by endoscopic sinus surgery in material of Otolaryngology Department of Medical University in Białystok]

Over the last years we have observed a high frequency of fungal infections of the paranasal sinuses. Fungal infections can be grouped into invasive and non-invasive forms. Surgical removal of the sinus fungal masses to ensure drainage and aeration is performed using the endoscopic sinus surgery. General or local antifungal drugs are not indicated in the cases of non-invasive forms. For the treatment of invasive fungal sinusitis aggressive antifungal therapy and surgical treatment are the mainstays of management. The treatment results of 18 patients suffering from fungal infections of the paranasal sinuses operated endoscopically during 4 years period (2006-2009) in Otolaryngology Department of Medical University in Białystok were presented.

Characteristics of Isolated Sphenoid Sinus Aspergilloma: Report of Twelve Cases and Literature Review

Objectives:

Isolated sphenoid sinus aspergilloma (ISSA) is a form of fungal sinus infection that is distinct from allergic fungal sinusitis, invasive fungal disease, and Aspergillus granulomas. In this study, we identify the characteristics of patients with ISSA to achieve timelier intervention for this easily neglected disease.

Methods:

In a retrospective study of patients with ISSA in our institution (1995 to 2006), 12 were identified.

Results:

Sixty-seven percent of our patients were more than 50 years of age, and a female preponderance was noted. Headache and postnasal drip were the two most common symptoms, and the samples from 78% of our patients with postnasal drip were blood-tinged. Computed tomographic scanning provided a sensitivity of 64%, whereas endoscopic examination failed to identify abnormalities in any patients.

Conclusions:

Four characteristics were identified in the diagnosis of ISSA: Female; usually above 50 years of age; with postnasal drip (especially blood-tinged); and headache (particularly periorbital or retro-orbital).

Invasive Aspergillus terreus sinusitis with orbitocranial extension: case report

BACKGROUND

Aspergillosis of the paranasal sinuses is infrequent and usually involves the species Aspergillus fumigatus and A. flavus. The maxillary sinus is the most common sinus to be affected. Invasive cranio-orbital aspergillosis originating in the sphenoid sinus is rare and mostly occurs in immunocompromised patients with poor outcomes. We present a case of invasive A. terreus sphenoidal sinusitis with intraorbital and intracranial extension in an immunocompetent patient.

CASE DESCRIPTION

This 62-year-old man presented with a 2-month history of left retroorbital pain followed by rapid decreasing vision and 2 episodes of epistaxis. Ophthalmologic examination revealed no light perception left. Computed tomographic scan and MR images demonstrated an enhanced sphenoid lesion within the left sphenoid sinus with bone destruction and intraorbital and cavernous sinus extensions. A malignant tumor was suspected. The patient underwent a transphenoidal biopsy of the sphenoid mass. Histologic analysis revealed numerous Aspergillus hyphea, and the species A. terreus was isolated from fungal cultures of specimens. No systemic fungal infection was found, and the patient had no evidence of immunosuppression. After 3 months' administration of oral voriconazole, the patient became well, and the orbitocranial mass regressed in size. It was stabilized on the ninth postoperative month.

CONCLUSION

A. terreus sinusitis with orbitocranial extension had never been reported in the literature. Even in an immunocompetent host, ISOA is difficult to eradicate using surgical debridement combined with optimal antifungal agents because of the intracranial extension and the relative resistance of conventional antifungal therapy. Early diagnosis is important to prevent an unfavorable outcome of this emergent infection.

Invasive sphenoidal aspergillosis: successful treatment with sphenoidotomy and voriconazole

Treatment of invasive sphenoidal aspergillosis is surgical, followed by antifungal therapy, mostly amphotericin B. To optimize the adjuvant antifungal treatment, which is often limited by severe side effects, the new triazole antifungal agent voriconazole with broad coverage of fungal pathogens including Aspergillus was investigated in a study of 4 patients with clinical, radiological and histological signs of invasive sphenoidal aspergillosis. They first underwent endoscopic sphenoidotomy with drainage and extraction of the fungal mass. Postoperatively, 2 patients were immediately treated with voriconazole. Two patients initially received amphotericin B; but this treatment had to be stopped because of acute renal toxicity. Finally, all patients were treated orally with 200 mg voriconazole twice a day for 12-14 weeks. After this combined treatment all patients were asymptomatic and there were no endoscopic or radiological signs of residual fungal disease. The only side effects were nausea in one and transient visual disturbances in 2 other patients. In the 4 patients presented and treated, voriconazole was shown to be effective and less toxic than amphotericin B in adjuvant treatment of invasive sphenoidal aspergillosis.

An unusual presentation of sphenoid sinusitis with septicaemia in a healthy young adult

Streptococcus pneumonia and Haemophilus influenzae account for more than 50% of bacterial acute sinusitis. Isolated sphenoid sinusitis is a rare disease with potentially devastating complications such as cranial nerve involvement, brain abscess, and meningitis. It occurs at an incidence of about 2.7% of all sinus infections. There have been no previous reported cases of unilateral sphenoid sinusitis presenting as septicaemia in an otherwise healthy young immunocompetent adult.

Middle and posterior fossa aspergilloma

BACKGROUND

Aspergilloma of the brain is a rare disease. Among its varied presentations, a solitary intracranial mass is very uncommon. A preoperative diagnosis of it is very difficult, but a perioperative squash smear/frozen section can identify the pathology. Because of its rarity in immunocompetent patients and the difficulty in preoperative diagnosis, we have illustrated this case and its presentation and management.

METHODS

A 27-year-old man presented with an h/o right-sided weakness along with headache and ear discharge. A computed tomographic (CT) scan showed a large irregular, space-occupying lesion in the middle and posterior cranial fossa. He had a mastoidectomy done 3 years before for chronic suppurative otitis media. After a symptom-free interval of 1 year, he was investigated for severe earache on the same side. A CT scan at that time showed a space occupying mass in the right temporal bone and right inferior temporal lobe. A biopsy and histopathology of the lesion revealed a chronic granulomatous mass. He was started on antituberculous drugs and was on it for 7 months at the time of presentation.

RESULTS

He underwent a suboccipital craniectomy and total excision of the mass. Postoperatively, his consciousness improved but began to deteriorate on the third postoperative day. A repeat CT scan showed hydrocephalus and total removal of the mass. An external ventricular drain was put and he was ventilated, but he died on the fourth postoperative day. Histopathology report came as aspergilloma.

CONCLUSION

This report highlights the rare presentation of aspergilloma in an immunocompetent patient. It emphasizes the importance of suspecting this disease in such patients and the role of intraoperative squash smear preparations or frozen section in the diagnosis as routine diagnostic procedures that will help in early pharmacotherapeutic interventions in adjunct to surgery.

Orbital apex syndrome

PURPOSE OF REVIEW

Visual loss from optic neuropathy and ophthalmoplegia involving multiple cranial nerves are the hallmarks of an orbital apex syndrome. Historically, the terms superior orbital fissure, orbital apex, and cavernous sinus have been used to define the anatomic locations of a disease process. However, the diagnostic evaluation and management is similar for each of these entities. The authors reviewed the literature on the diagnosis and evaluation of disorders involving the orbital apex.

RECENT FINDINGS

High-resolution MRI is the preferred modality for evaluating most lesions involving the orbital apex. CT is a useful tool in the setting of trauma, to evaluate bone involvement, or when MRI is contraindicated. Although laboratory studies may be useful adjuncts in the diagnostic evaluation of lesions involving the orbital apex, surgical biopsy is often required for definitive diagnosis.

SUMMARY

Orbital apex syndromes may result from a variety of inflammatory, infectious, neoplastic, iatrogenic/traumatic, and vascular conditions. A detailed history with review of systems is important in narrowing the differential diagnosis. Management is directed at the underlying cause and may be guided by surgical biopsy. Corticosteroids may be useful if an inflammatory etiology is suspected, but should be used with caution.