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

Multidisciplinary approach to severe intracranial, intraorbital allergic fungal sinusitis

BACKGROUND

Allergic fungal sinusitis (AFS) is a form of paranasal mycosis that often involves bone destruction and can extend into the orbit and anterior skull base. Intracranial and intraorbital involvement are published but not both in each included patient of a series. The purpose of the present study was to review cases of extensive AFS with orbital or/and skull base erosion, including the presenting symptoms, patient socioeconomic background, imaging features, surgical technique, and post-operative outcomes.

METHODS

The records of 30 patients with the histological diagnosis of AFS and both intracranial and intraorbital involvement were reviewed.

RESULTS

The average age of the patients was 25.2 years. 83 % of patients were male. 70 % were African American. 66 % of patients had Medicaid or were uninsured. Presenting symptoms were headaches (80 %), nasal obstruction (33 %), proptosis (40 %), vision change (23 %), facial pressure (10 %), and decreased sense of smell (7 %). 100 % of patients had bone erosion observed on computerized tomography scans with disease extending intracranially through the anterior skull base or posterior wall of the frontal sinus along with disease that eroded through the lamina papyracea. All patients had failed medical management. All patients underwent surgery by Otolaryngology, Ophthalmology, and Neurosurgery with transnasal endoscopic approaches and orbitotomy. 80 % also underwent a bifrontal craniotomy for removal of intracranial extradural disease with cranialization. 53 % of patients had orbital implants remaining after surgery; 23 % had nasal stents. There were no postoperative cerebrospinal fluid leaks. Average hospital stay was 4.8 days. Preoperatively, 13 % of patients underwent allergy testing. 94 % saw an Allergist postoperatively. 21 % required follow up surgery.

CONCLUSIONS

A team approach of Otolaryngologists, Ophthalmologists, and Neurosurgeons is recommended for this slowly growing but locally destructive disease. Most patients with AFS will present with headaches and nasal obstruction. While most cases of AFS can be successfully managed with transnasal endoscopic techniques, orbitotomy and craniotomy represents an effective treatment for severe AFS cases with extensive intracranial and intraorbital involvement. This disease is found most commonly in young African American males and in the underinsured.

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.

Isolated Acute Sphenoid Fungal Sinusitis with Cavernous Sinus Thrombosis: Our Experience

Isolated lesions of the sphenoid sinus are uncommon. Cavernous sinus thrombosis is generally sought due to a systemic disease rather than a local pathology. It may be due to hidden primary pathology like isolated acute sphenoid fungal rhinosinusitis. In present study, we  have discussed the early management of such hidden lesions with complication. A retrospective review of 5 cases of isolated acute sphenoidal fungal rhinosinusitis leading to cavernous sinus thrombosis was carried out. All cases were managed as emergency cases. Diagnostic nasal endoscopy was normal in all cases, with sinus disease evident in radiology in only 60% cases. Diagnostic endoscopic sinus surgery was performed in 40% cases. All patients underwent urgent surgical debridement along with IV antifungals. Complete recovery was seen in ocular movements in 40% and partially in 40%, whereas only 25% had complete improvement in vision. While four cases showed favourable outcome, one patient could not be saved despite all efforts. Exploring the sinus in cavernous sinus syndrome or orbital apex syndrome despite non-conclusive imaging, is warranted as early intervention may significantly impact the chances of survival. "Time is vision" in cases with acute fungal sinusitis and is equal to the aphorism of cardiologists i.e. "time is muscle.

Isolated Sphenoid Sinusitis: Anatomical Features for Choosing a Method of Treatment, a Case-Control Study

Isolated sphenoid sinusitis (ISS) is a group of pathologies characterized by inflammation in one or both sphenoid sinuses. The gold standard for analyzing and diagnosing ISS is computer tomography. Many researchers have discussed the treatment of patients with ISS variants such as fully opacified sinus, mostly with surgery. A retrospective analysis of clinical data of 59 patients (21 male (35%), 38 female (65%)) with ISS, who were treated in the Otorhinolaryngological Department of Pavlov First Saint Petersburg State Medical University between January 2017 and January 2020, was conducted. All patients were in the first stage of the same medical therapy. In cases where there was no recovery, these patients were referred to surgery. For the control group, we analyzed patients without any disorders according to CT-scan examination. After analyzing the obtained clinical and radiological data, we found indicators that were common in patients who did not recover after medical therapy. According to the reverse regression method statistical model, in male patients with a diffuse headache and nasal discharge it was shown that medical therapy was highly effective (more than 78%). The presence of nasal septum deviation and adenoids in male and female patients leads to the highest risk of surgical treatment (83% probability of the logistic model). The detailed analysis of CT-scans and the complaints of patients with ISS can be the key to determining the preferred therapy choice. Not all cases need to have an endoscopic opening of the sphenoid sinus, according to our research.

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

•

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

•

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

•

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

•

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.

The clinical features of endoscopic treated isolated sphenoid sinus diseases

BACKGROUND

Isolated sphenoid sinus disease (ISSD) is a rare clinical entity with potentially serious complications. The etiological distribution of ISSD varies among different areas and ethnicities. We aimed to investigate the clinical features of patients with endoscopic treated ISSD.

METHODS

We retrospectively reviewed all patients with ISSD who had undergone endoscopic surgery between April 2013 and May 2019. The patient records were reviewed for demographic data, clinical presentations, endoscopic and imaging study findings, surgical outcomes and complications.

RESULTS

A total of 37 patients with ISSD who underwent surgery were recruited. We divided patients into three groups according to etiology, including inflammatory diseases (78.4%), neoplasms (13.5%) and spontaneous cerebrospinal fluid (CSF) leaks (8.1%); fungal ball (62.2%) constituted the major cause of ISSD. Overall, the most common presenting symptom was headache or facial pain (65.5%). The endoscopic findings of bloody discharge and tumor lesions were mainly from the neoplasm group. Bony defects were more obvious on computed tomography in the neoplasm and CSF leak groups. Magnetic resonance imaging revealed a higher rate of involvement of the cavernous sinus (40.0%) and intracranial extensions (40.0%) in the neoplasm group. To summarize the surgical outcomes, the success rate was 97.1%, and the major complication rate was 5.4%.

CONCLUSION

ISSD represents a variety of etiologies, mostly comprising fungal ball in our area, while there is still a considerable proportion of ISSDs attributed to neoplasm and CSF leak. Untreated ISSD can result in serious complications. We recommend early surgical intervention for all patients with ISSD.

An unusual presentation of sphenoid Candida fungal ball: a case report

The clinical presentation of a sphenoid fungal ball (FB) is often non-specific and tends to be overlooked, particularly in hosts with an intact immune status. Rarely, potentially life-threatening complications may arise, owning its anatomical characteristics with contiguous structures. Herein, we present an unusual case of sphenoid FB complicated with orbital apex syndrome in an immunocompetent patient. The diagnosis dilemma and subsequent management are further discussed.