Fungal Rhinosinusitis: A Radiological Review with Intraoperative Correlation

Abstract

The interaction between fungi and the sinonasal tract results in a range of clinical presentations with a broad spectrum of clinical severity. The most commonly accepted classification system divides fungal rhinosinusitis into invasive and noninvasive subtypes based on histopathological evidence of tissue invasion by fungi. Invasive fungal rhinosinusitis is subdivided into acute invasive and chronic invasive categories. The chronic invasive category includes a subcategory of chronic granulomatous disease. Noninvasive fungal disease includes localized fungal colonization, fungal ball, and allergic fungal rhinosinusitis. Noninvasive disease is simply fungal material (or the products of the inflammatory reaction of the sinus mucosa) that fills the sinuses but does not invade tissue. Bone loss is related to expansion of the sinus(es). Invasive disease causes tissue destruction, such that it expands past the bony confines of the sinuses. It can rapidly spread, causing acute necrosis. Alternatively, there may be slow tissue invasion characterized by symptoms confused with normal sinusitis, but destruction of normal nasal and paranasal structures.

A retrospective analysis of 1,717 paranasal sinus fungus ball cases from 2008 to 2017

“…Computed tomography (CT) scans have revealed the opacity of the cavity associated with a hyperdense area within the lesion and including thickened bone . From the microbiological viewpoint, Aspergillus fumigatus is the most frequent fungus found in FB at present.…”

Isolated fungus ball in sphenoid sinus: tips and pitfalls of T1 hyperintense lesions

“…Fungal rhinosinusitis (FRS) is one of the most common pathologies that affects paranasal spaces, and radiological imaging plays an important role in its identification. 5 , 6 FRS is distinguished into two categories: invasive, which usually affects immunosuppressed patients and is characterized by the infiltration of the mucosa and spreading to the surrounding structures; non-invasive FRS, typically affecting immunocompetent patients, with no evidence of tissue invasion. 5 , 7 Paranasal sinus FB was first described in the 18th century and defined as extramucosal accumulation of dense conglomeration of fungal hyphae in a solitary sinus cavity.…”

“… 5 , 10,12 Isolated sphenoidal sinus FB is a relatively rare entity that is more frequent in elderly female patients and may present with vague symptoms. 6 Until 1992, only 21 cases of isolated sphenoid sinus FB were reported and this might have been due to its vague presentation and lack of advanced imaging tools. Nowadays, the incidence is increasing.…”

“…CT scan is the modality of choice for diagnosis, and MRI should be done if bone involvement is suspected; however, there are no pathognomonic imaging features and this is why histopathological confirmation should be done postoperatively. 6 Generally, functional endoscopic sinus surgery is the modality of choice for management with no further medical treatment required. In our opinion, on the basis of previous considerations, this pathology may be underdiagnosed on routine evaluation and sometimes wrongly interpreted as simple sinusitis, with possible life-threatening complications.…”

Utility of Pre-Hematopoietic Cell Transplantation Sinus CT Screening in Children and Adolescents

“…for the presence or absence of bone destruction, extrasinus inflammation, and nasal mucosal ulceration, associated with IFRS. 4,[19][20][21][22] Because noninvasive fungal disease could theoretically predispose to IFRS with pre-HCT conditioning/immunodepletion, the presence of calcifications and sinus hyperdensity was also noted. 23 Each anterior and posterior ethmoid, maxillary, frontal, and sphenoid sinus was graded as clear ¼ 0, partially opacified ¼ 1, or completely opacified ¼ 2; each ostiomeatal unit was graded as clear ¼ 0 or occluded ¼ 2; and the numbers were added per Lund and Mackay.…”