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

Periantral fungal abscess after zygoma reduction: a case report

This case report describes our treatment of a persistent periantral abscess in a 35-year-old woman. The abscess developed following a zygoma-reduction surgery, during which a preexisting fungal ball had not been addressed. Our comprehensive treatment approach included functional endoscopic sinus surgery, fungal ball removal, abscess drainage, and debridement. Two weeks postoperatively, the patient's symptoms had resolved. A 6-month postoperative follow-up revealed no signs of recurrence or complications, and the patient reported satisfactory functional and aesthetic results. This case underscores the importance of thorough preoperative evaluations and raises awareness about the potential risks of untreated asymptomatic pathologies, which can potentially progress and lead to further complications.

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.

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.

Intermediate Invasive Fungal Sinusitis, a Distinct Entity From Acute Fulminant and Chronic Invasive Fungal Sinusitis

BACKGROUND

The current classification system of invasive fungal sinusitis (IFS) includes acute (aIFS) and chronic (cIFS) phenotypes. Both phenotypes display histopathologic evidence of tissue necrosis, but differ by presence of angioinvasion, extent of necrosis, and disease progression. aIFS is defined by a rapid onset of symptoms, while cIFS slowly progresses over ≥12 weeks. However, a subset of IFS patients do not fit into the clinical presentation and histopathologic characteristics of either aIFS or cIFS.

OBJECTIVES

To investigate the demographic, clinical, and histopathologic characteristics of a distinct subset of IFS.

METHODS

Retrospective review of patients with IFS from a single tertiary-care institution (2010-2020). Patients with symptoms for ≤4 weeks were classified as aIFS if they displayed endoscopic evidence of mucosal necrosis or fungal angioinvasion on pathology. Patients with slowly progressive IFS for ≥12 weeks were classified as cIFS. Patients with symptom duration between 4 and 12 weeks with evidence of invasive fungal disease were classified as a new entity and were further investigated.

RESULTS

Of the 8 patients identified, 50% were immunosuppressed at presentation. The mean symptom duration prior to presentation was 50.5 days (SD 16.8), and common symptoms included facial pain (100%), vision change (87.5%), and blindness (37.5%). Two patients (25%) died of their disease. Sites of fungal involvement confirmed by histopathology included sphenoid (62.5%) and ethmoid sinuses (12.5%), orbital apex (25%), optic nerve (12.5%), pterygopalatine fossa (12.5%), and clivus (12.5%). Fungal elements but without obvious angioinvasion, were identified in all specimens, and fungus balls (50%), granulomas (37.5%), and giant cells (25%) were also observed on histopathology. CT and MRI radiographic imaging showed findings consistent with orbital, intracranial, or skull base involvement in all patients.

CONCLUSION

We propose intermediate IFS as a new subgroup of patients with IFS who do not fit into the standard classification of aIFS or cIFS.

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.

Treatment of Paranasal Sinus Fungus Ball: A Systematic Review and Meta-Analysis

OBJECTIVES

Paranasal sinus fungus ball is a common non-invasive mycosis with excellent long-term surgical treatment results. The present systematic review and meta-analysis were undertaken to define current treatment concepts and success rates in paranasal sinus fungus ball treatment.

METHODS

Systematic searches were performed in multiple databases with criteria designed to include all studies published until May 2020 focusing on paranasal sinuses fungus ball treatment in humans. We selected studies including at least 10 patients, specifying treatment modalities, providing a minimum 6-month follow-up, and objectivating treatment success. After duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for treatment modalities and success rates. Success rates were pooled in a random effect meta-analysis and compared according to the use of intraoperative sinus lavages and postoperative antibiotics.

RESULTS

Among 740 unique citations, 14 studies were deemed eligible. Most (n = 11) were retrospective case series. All studies relied on endoscopic sinus surgery. Intraoperative lavages were proposed in 10 studies and postoperative antibiotics in 7 (for all patients in 5 studies and for selected patients in 2). No significant heterogeneity was observed between results (Cochran's Q P = .639, I² test = 0). Treatment success rate was 98.4% (95% confidence interval 97.4%-99.3%). Intraoperative sinus toilette and postoperative antibiotics didn't significantly improve the success rate.

CONCLUSION

Endoscopic sinus surgery shows excellent results in fungus ball treatment. Further prospective studies might help further reducing antibiotics prescriptions in these patients and improve their management.

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.

Diverse phenotypes and endotypes of fungus balls caused by mixed bacterial colonization in chronic rhinosinusitis

BACKGROUND

The pathogenic roles of fungus and bacteria in chronic rhinosinusitis (CRS) remain unclear. Recently, we described the bacterial ball, which is distinct from the fungus ball, as an unusual phenotype of bacterial infection. In this study, we investigated the clinical, histopathologic, and immunologic characteristics of sinonasal microorganic materials, including fungus ball and bacterial ball.

METHODS

In this study, we enrolled 80 CRS patients with sinonasal microorganic materials and 10 control subjects who underwent skull base surgery or endoscopic dacryocystorhinostomy and had no signs or symptoms of nasal inflammation. All specimens were stained with hematoxylin-eosin, Gomori-methenamine-silver, and Gram stain to identify fungal organisms and Gram-positive/negative bacterial colonies. The expression of tumor necrosis factor (TNF)-α; interleukin (IL)-1β; S100A7; S100A8/A9; and short, palate, lung, and nasal epithelial clone 1 (SPLUNC1) were evaluated by enzyme-linked immunosorbent assay using sinus lavage fluid.

RESULTS

We histologically classified sinonasal microorganic materials into the following 4 groups: fungus ball (n = 45); bacterial ball (n = 6); mixed ball (formed by a mixture of fungus and bacteria, n = 27); and double ball (formed by separate fungal and bacterial balls, n = 2). Compared with the fungus ball, the mixed ball was more frequently detected in immunocompromised patients (p < 0.0001). In addition, TNF-α expression was significantly higher in fungus and mixed balls than in control, whereas the mixed ball showed higher expression of IL-1β compared with the fungus ball. Moreover, the expression of S100A7 and S100A8/A9 protein in the mixed ball was significantly decreased when compared with the fungus ball, whereas there was no significant difference in SPLUNC1 expression between fungus and mixed balls.

CONCLUSION

Our findings suggest that fungal and bacterial interactions are diverse in CRS. Specifically, the mixed ball is prevalent in CRS with an immunocompromised state and it may decrease epithelial barrier function.