Fungal Sinusitis

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F u n g a l Si n u s i t i s

Eytan Raz, MD, William Win, MD, Mari Hagiwara, MD, Yvonne W. Lui, MD,
Benjamin Cohen, MD, Girish M. Fatterpekar, MD*

KEYWORDS
 Invasive fungal sinusitis  Noninvasive fungal sinusitis  Granulomatous fungal sinusitis
 Allergic fungal sinusitis

KEY POINTS
 Fungal sinusitis is classified into invasive and noninvasive forms based on histopathologic evidence
of tissue invasion by fungi.
 The invasive category includes acute invasive, chronic invasive, and granulomatous forms.
 The noninvasive category includes allergic fungal sinusitis and mycetoma.
 Each of the subtypes of fungal sinusitis has a different clinical presentation, distinct from the other
forms, is associated with unique radiologic features, and a specific treatment plan.

INTRODUCTION based on the clinical presentation, imaging evi-


dence and/or histopathologic confirmation is
Among causes of sinonasal inflammatory disease, required. Patients with noninvasive form typically
fungal sinusitis is a relatively uncommon but well- present with chronic sinusitis that fails to respond
established clinical entity. Fungi are ubiquitous in to repeated courses of antibiotics and surgeries.2
the environment, and can colonize the upper respi- Invasive fungal sinusitis usually occurs with an
ratory tract mucosa when fungal spores are acute onset characterized by fever, cough, and
inhaled. In people with normal immune function, occasionally nasal mucosal ulceration. Usually
the fungal growth is kept in check. With impaired this invasive form is seen in immunocompromised
host immunity, fungi can invade host mucosa and patients. There are chronic forms of invasive dis-
cause invasive disease. Clinicians should therefore ease that can have an innocuous presentation,
maintain a high index of suspicion of fungal sinus- but usually demonstrate progressive worsening
itis in immunocompromised patients with sinusitis, of symptoms suggestive of involvement of adja-
and those with chronic sinusitis. Fungal sinusitis cent structures, such as associated visual distur-
consists of a heterogeneous group of disorders, bance suggesting orbital invasion.
with diversity in the affected patient population, of- This article first explains the classification of
fending agents, mechanism of disease, clinical fungal sinusitis, and then evaluates separately
presentation, histopathology, imaging appear- the different entities with a particular focus on
ances, treatment, and overall prognosis.1 the radiologic appearance, and the information
Fungal sinusitis is broadly classified into two that the clinician needs to know to institute an
major groups: invasive and noninvasive forms. appropriate therapy.
Although fungal sinusitis can be caused by any
fungus, most result from Aspergillus infection.
CLASSIFICATION OF FUNGAL SINUSITIS
The invasive form is distinguished from the nonin-
vasive variety depending on the presence of fungal
neuroimaging.theclinics.com

The first attempt to classify fungal sinusitis was


elements outside the paranasal sinuses. It should made in 1965, when two subtypes were recog-
be noted that although the distinction between nized: a noninvasive form, clinically similar to
invasive and noninvasive forms is suggested chronic bacterial sinusitis; and an invasive form,

Department of Radiology, NYU School of Medicine, 660 First Avenue, 2nd Floor, New York, NY 10016, USA
* Corresponding author.
E-mail address: Girish.Fatterpekar@nyumc.org

Neuroimag Clin N Am - (2015) -–-


http://dx.doi.org/10.1016/j.nic.2015.07.004
1052-5149/15/$ – see front matter Published by Elsevier Inc.
2 Raz et al

where the infection mimicked a disease similar to a NONINVASIVE FUNGAL SINUSITIS


tumor with bone erosion with invasion into adjacent Allergic Fungal Sinusitis
tissues.3 The most commonly accepted classifica-
AFS is the most common form of fungal sinusitis,
tion system, based on International Society for Hu-
and is common in humid climates.9 The overall
man and Animal Mycology Group, February 2008,
incidence of AFS is estimated at 5% to 10% of
categorizes fungal sinusitis into invasive and nonin-
all hypertrophic sinus disease cases going to sur-
vasive types based on histopathologic evidence of
gery.10 It was first reported as allergic aspergillosis
tissue invasion by fungi.4 The noninvasive subtypes
by Millar and colleagues in 198111 who noted the
include allergic fungal sinusitis (AFS) and myce-
similarity of the fungal-containing sinus exudate
toma; the invasive subtypes include acute invasive
characteristic of this condition to the one found
fungal sinusitis, chronic invasive fungal sinusitis,
in the bronchi of patients affected by allergic bron-
and granulomatous invasive fungal sinusitis.4
chopulmonary aspergillosis.
AFS refers to noninvasive collection of impacted
GENERAL IMAGING CONSIDERATIONS mucus and cellular debris, resulting from an
allergic response to fungal colonization within the
There are certain characteristic computed tomog-
sinus cavity.4 It should be noted that the amount
raphy (CT) and MR imaging findings that are highly
of fungal elements within the opacified sinus is
suggestive of fungal sinusitis.5,6 Imaging overall
variable, often times scanty. The secondary in-
therefore plays a key role in evaluating patients
flammatory process that results does not depend
with suspected fungal sinusitis. Noncontrast CT
on the quantity of fungus present. Hence, the
remains the initial imaging study of choice in the
role of fungi in initiating or promoting this disease
work-up of fungal sinusitis.7,8 In cases of compli-
is controversial and by some, thought to be
cated especially invasive fungal sinusitis, MR im-
circumstantial.4
aging can be performed for a more definitive
The typical patient with AFS is young, atopic,
evaluation.7 CT in general is better in assessing
immunocompetent, and presents clinically with hy-
for hyperattenuation within the opacified sinus,
pertrophic sinus disease experiencing chronic
which in an appropriate clinical setting can sug-
headaches, nasal congestion, and chronic sinus-
gest fungal infection. MR imaging is better at eval-
itis for several years.9 Fungal-specific IgE as
uating disease extension into adjacent soft tissues,
detected by type I hypersensitivity skin testing is
including soft tissues of the neck, such as pterygo-
a constant feature. Total serum IgE is elevated,
maxillary fissure, orbit, intracranial compartment,
up to 5000 IU/mL, with a mean of 600 IU/mL
and vasculature.6
commonly seen.12 Originally considered to be
On CT, inflammatory watery secretions are seen
caused solely by Aspergillus species, other
as low-attenuation. As the inflammatory sinus dis-
causative fungi commonly reported include dema-
ease persists, the secretions become inspissated
tiaceous fungi, such as Bipolaris, Curvularia, Alter-
and demonstrate a higher attenuation than muscle.
naria, and Fusarium.
In cases of fungal sinusitis, calcium and magnesium
Within affected sinuses, “allergic mucin” is
salts become deposited in areas of fungus growth
found, characterized by a purulent, yellow-green
and fungus-infected mucin.6 These fungal concre-
and sometimes black mucus, which at histopatho-
tions appear hyperdense on noncontrast CT.
logic analysis reveals the presence of eosinophil
MR imaging appearance of secretions depends
granulocytes and Charcot-Leyden crystals, which
on their protein content, viscosity, and presence of
are eosinophil degradation products.13–15 Fungal
calcifications. Watery secretions usually contain
hyphae are sparse and noninvasive, and may be
less than 5% protein content; they appear as low
identifiable by special stains, such as Gomori
signal intensity on T1-weighted images and high
methenamine silver stain. Given the specific histo-
signal intensity on T2-weighted images. As they
pathologic findings, the presence of allergic mucin
become inspissated, the secretions contain higher
is virtually diagnostic for AFS, sometimes even in
percentage of protein content (between 5% and
the absence of fungal identification.
25%). Increasing T1 signal intensity is noted on
T1-weighted images and a variable signal is seen
on T2-weighted images. Within sludge or myce- Imaging features
toma where protein content can be between On imaging, there is unilateral or asymmetric
25% and 40%, low signal intensity on T1- involvement of the sinuses. Characteristically, mul-
weighted images, and low signal or signal void tiple sinuses are involved. Maxillary and ethmoid
on T2-weighted images are seen. This last pattern sinuses are most commonly involved. Noncontract
has been described to be highly suggestive of CT shows hyperdense areas within the sinus cav-
fungal sinusitis.6 ities outlined by hypodense-appearing thickened
Fungal Sinusitis 3

and inflamed mucosa (Fig. 1).16,17 Depending on lesion is formed. Affected patients are immuno-
the contents of the material, the MR imaging signal competent, nonatopic, and otherwise healthy.
is variable, ranging from isointense to hypointense Some studies have reported the disease to be
signal to signal void on T1- and T2-weighted im- more common in older women. However, patients
ages. This signal heterogeneity is related to the of all ages are affected. The maxillary sinus by far
presence of deposited heavy metals, such as iron is the most common site of occurrence. It has
and manganese. On contrast-enhanced studies, been postulated that the host’s deficient mucocili-
the intrasinus contents usually demonstrate no ary clearance mechanism is accountable for the
masslike enhancement. Because of the expansive disease. This allows the uncleared fungal elements
nature of allergic mucin, and its propensity to incite to colonize and proliferate in the retained secre-
local inflammatory response, sinus expansion tions within the sinonasal cavity, inciting an inflam-
along with osseous remodeling and erosive matory response. Previous endodontic treatment
changes of the sinus walls are seen.18 and radiotherapy are sometimes implicated in
the development of a mycetoma. Aspergillus
Treatment fumigatus is the most commonly implicated
Endoscopic removal of polyps and inflammatory pathogen.21
material, including mucin, to re-establish aeration
and drainage of involved sinuses is essential Clinical diagnosis
for successful treatment.19 Following surgery, Typically, medical attention is sought for mild sinus
additional measures including the use of topical pressure. In some cases, patients are asymptom-
steroids for immune response suppression is atic and the diagnosis is made incidentally on im-
important to prevent recurrences; this concept aging. A surgical specimen of a fungal mycetoma
was actually derived from experience with allergic has been described as a thick, semisolid mass
bronchopulmonary aspergillosis. Other therapies, with “claylike” consistency. Histopathologic ex-
such as immunotherapy, antihistamines, oral anti- amination reveals tightly packed fungal hyphae
leukotrienes, oral steroids, and nasal irrigation, are without allergic mucin, a feature distinct from
helpful in certain clinical situations.12,20 AFS.2 Calcium oxalate deposition often accom-
panies the growth of Aspergillus, and appears as
Fungus Ball radiating clusters of birefringent crystals on
histochemistry.
Fungus ball, also referred to as a fungal mycetoma
or aspergilloma, is reported as a distinct clinical Imaging features
entity and a discrete form of noninvasive fungal si- Characteristic imaging findings are critical to the
nus disease.6 It refers to an indolent growth of diagnosis. Typically, a single sinus cavity is
fungal hyphae in a sinus cavity until a masslike affected, a distinct feature from other forms of

Fig. 1. Allergic fungal sinusitis in a 72-year-old woman with history of nasal polyposis. Noncontrast (A) axial and
(B) coronal CT scans demonstrate opacified paranasal sinuses and nasal cavity relatively sparing the left maxillary
sinus. Hyperdensity seen within opacified sinuses suggests a mixture of inspissated secretions and fungal
concretions.
4 Raz et al

fungal sinusitis.5,8 Maxillary sinuses are most patients typically include those with decreased
commonly affected, followed by sphenoid, frontal, host cell-mediated immunity, specifically with
and ethmoid sinuses. Another unique feature is the impaired neutrophil function, hematologic malig-
lack of sinus expansion. Because of its chronic na- nancies, aplastic anemia, hemochromatosis,
ture, osseous remodeling of the sinus wall can be poorly controlled diabetes, acquired immunodefi-
seen, noted as thickening and sclerosis. There is ciency syndrome, or organ transplantation; or are
opacification of the involved sinus with central undergoing immunosuppressive treatments, such
areas of high density and fine, round-to-linear ma- as systemic steroids or chemotherapeutic agents.
trix calcifications (Fig. 2). T1-weighted images Infrequently, acute invasive disease has been re-
demonstrate low signal intensity of the thick, solid, ported in patients with normal immune function.24
mycetomatous mass, although the signal can be Aspergillus sp and members of the family Mu-
heterogeneous depending on the content.5,8 coraceae (Mucor, Rhizopus, and Absidia) are
Because of the presence of calcifications and implicated in most cases of acute invasive fungal
paramagnetic metals, such as magnesium, iron, sinusitis. In poorly controlled diabetics, Mucor,
and manganese, low T2 signal intensity is also Rhizopus, and Absidia predominate, and in neutro-
observed. Contrast-enhanced studies demon- penic patients, Aspergillus sp account for most
strate thickening and enhancement of the cases.22
surrounding inflamed mucosa. There is no involve- As expected in this patient population, the dis-
ment of the soft tissues surrounding the involved ease course is rapidly progressive and can prove
sinus cavity.5 to be fatal within days to weeks. Therefore, it is
important for clinicians to maintain a high level of
Treatment and prognosis awareness, and for radiologists to proactively
Good prognosis is noted following surgical exci- look for subtle changes that can be identified in
sion and reestablishing adequate sinus aeration.2 the early stages of the disease.

INVASIVE FUNGAL SINUSITIS Clinical features


Acute Invasive Fungal Sinusitis The presenting symptoms are nonspecific and
include fever, headache, rhinorrhea, facial pain,
Acute invasive fungal sinusitis is a fungal infection and diplopia, which can also be seen with acute
of nasal cavity and paranasal sinuses with a rapid bacterial sinusitis. Therefore, when sinusitis is
progressive time course (<4 weeks).22,23 There is considered in patients with impaired immune func-
associated invasion of fungal elements into ves- tion, appropriate diagnostic work-up, including im-
sels and adjacent soft tissues. Affected patients aging studies and nasal endoscopy with possible
tend to be critically ill, and demonstrate some de- biopsy, must be initiated in a timely manner.
gree of compromised immune function. Such Involvement of the nasal cavity is common, with
the middle turbinate being the most commonly
affected site, thus a high-yield target for nasal bi-
opsy. On nasal endoscopy, the infected mucosa
appears pale, progressing to ulceration and tissue
necrosis with worsening disease. The affected
area is commonly painless. Definitive diagnosis is
made with microscopic identification of invasive
fungi in the biopsy samples of mucosa, submu-
cosa, vessels (angioinvasion), and bone. Infarcted
tissue and inflammatory cellular infiltrates are also
seen.

Imaging features
Maxillary and ethmoid sinuses are most commonly
affected. On CT, mucosal thickening with partial or
complete opacification of the affected sinus is a
Fig. 2. Fungal mycetoma in a 41-year-old woman pre-
typical imaging feature8,23 Hyperattenuation areas
senting with sinus pressure. Noncontrast axial CT scan
demonstrates an opacified left maxillary sinus. Central within the opacified sinuses are commonly seen,
hyperdensity seen within is suggestive of fungal con- and in an immunocompromised state should raise
cretions. Note the circumferential thickening of the a red flag for an underlying fungal cause. This is
osseous walls of the left maxillary sinus, a finding especially concerning when associated soft tis-
consistent with a chronic inflammatory process. sue/vascular invasion, as suggested of effacement
Fungal Sinusitis 5

of fat, beyond intact sinus walls is seen (Fig. 3). In such as the cavernous segment of internal carotid
such cases, disease spread is thought to occur arteries for thrombosis, dissection, and pseudoa-
through microvascular channels present within neurysm formation (Fig. 5).
the bone. The areas to be particularly mindful of
to evaluate for such soft tissue infiltration are Treatment
spaces adjacent to maxillary sinuses, such as pre- Treatment consists of emergency surgical
maxillary and retroantral fat, and pterygopalatine debridement and systemic antifungal agents.
fossa. Occasionally, focal areas of bone erosion Aggressive management of any inciting factor,
can be seen.23 On MR imaging, opacified sinuses such as diabetic ketoacidosis, is crucial in the
are seen. Within these opacified sinuses are areas management. The mortality associated with acute
of signal drop-out suggestive of fungal concretion. invasive fungal sinusitis has been traditionally
It should therefore be noted that appreciation of cited up to 50% to 80%.25 Despite a recent down-
such fungal concretion is therefore best made on ward trend, likely caused by better understanding
noncontrast CT, and can be a limitation of MR im- of the disease and timely diagnosis and initiation of
aging. However, invasion of adjacent soft tissues treatment, the mortality remains high, with some
is best assessed on MR imaging. With involvement studies reporting up to 18%.26 Studies have
of the spaces around the sinuses, there is T1 signal shown that overall mortality is higher in patients in-
intensity similar to soft tissue replacing normal fat fected with Mucor compared with those infected
signal intensity. Edematous change on T2- with Aspergillus sp.
weighted images, and enhancement within these
soft tissues is commonly seen. A unique feature Chronic Invasive Fungal Sinusitis
on imaging suggestive of invasive fungal sinusitis Chronic invasive fungal sinusitis is characterized
is the lack of enhancement in areas that should by an indolent course of the disease (>4–
typically enhance following contrast administra- 12 weeks), in contrast to the rapidly progressive
tion, such as the nasal mucosa and the turbinates. course of its acute counterpart.2,21 As with acute
Lack of enhancement of the affected mucosa of invasive disease, patients in immunocompromised
the turbinates, described as the black-turbinate states, such as poorly controlled diabetes mellitus
sign on imaging, is highly suggestive of tissue ne- or undergoing immunosuppressive treatments,
crosis, and is consistent with the angioinvasive na- show predisposition to the disease. Patients with
ture of fungal sinusitis (Fig. 4).23 For radiologists, it normal immune function are uncommonly
is also crucial to identify and alert clinicians of the affected.
extension of the disease, especially to the orbits
and intracranial compartment. In addition, the an- Clinical diagnosis
gioinvasive nature of some of the fungi makes it Patients usually seek medical attention for symp-
important to assess adjacent intracranial vessels, toms of chronic sinusitis, for which findings of

Fig. 3. Acute invasive fungal sinusitis in a 58-year-old man with neutropenia and right maxillary pain. (A) Non-
contrast axial CT scan demonstrates complete opacification of the right maxillary sinus with mixed attenuation
material. (B) At a level slightly cranial, CT scan demonstrates ill-defined soft tissue infiltration in the region of
the right pterygomaxillary fissure and soft tissues of the cheek. Also, note edematous change involving the right
masseter, temporalis, and pterygoid muscles suggestive of masticator space invasion.
6 Raz et al

Fig. 4. Acute invasive fungal sinusitis in a 33-year-old man with immunosuppression and acute right facial pain
and swelling. (A) Axial T2-weighted image demonstrates an opacified right maxillary sinus. Focus of hypoatten-
uation (arrow) is likely suggestive of fungal concretion. There is a suggestion of soft tissue infiltration within the
right pterygomaxillary fissure and edematous change within the right pterygoid muscles. (B) Contrast-enhanced
fat-suppressed coronal MR imaging demonstrates lack of “normal” enhancement of the right middle and inferior
turbinates suggestive of black turbinate sign. There is a suggestion of right orbital invasion and masticator space
invasion (arrows).

Fig. 5. Acute invasive fungal sinusitis in a 61-year-old woman with headache and change in mental status. (A)
Contrast-enhanced axial CT scan demonstrates nonvisualization of the medial wall of the left maxillary sinus sug-
gestive of recent surgical intervention. Opacified left sphenoid sinus is also seen. There is a suggestion of efface-
ment of the fat in the left pterygomaxillary fissure and edema within the left infratemporal fossa suggestive of
tissue invasion. (B) At a slightly more cranial level, there is no enhancement of the cavernous segment of the left
internal carotid artery suggestive of thrombosis and reflecting vascular invasion secondary to the angioinvasive
nature of fungal infection.
Fungal Sinusitis 7

protracted disease course, slow progression, and Treatment and prognosis


refractoriness to standard antibiotic treatment Treatment typically includes surgical debridement,
are common. In some cases, patients report followed by systemic antifungal agents, a strategy
decreased vision and ocular immobility, known similar to acute invasive fungal sinusitis. Although
as orbital apex syndrome. This has been reported the overall mortality is lower than the acute dis-
to be associated with disease extension to the ease, when there is invasion into adjacent struc-
orbital apex in patients with chronic invasive fungal tures, such as cavernous sinus or intracranial
sinusitis. The causative agent is known to be of compartment, a high mortality rate is reported.2
Aspergillus genus with A fumigatus being the
most common species. Except for the difference Granulomatous Invasive Fungal Sinusitis
in time course compared with the acute disease, Similar to chronic invasive fungal sinusitis, the dis-
the clinical and imaging work-up should be iden- ease course is slowly progressive. The affected
tical. Clinical examination reveals evidence of patients are usually immunocompetent and report
nasal congestion and nasal polyposis. On histol- a history of chronic sinusitis.2 This disease is prev-
ogy, the specimen includes material containing alent in Africa and Southeast Asia, with rare re-
densely packed hyphae, mixed with scattered, ported cases in the United States. The causative
chronic, inflammatory infiltrates. Evidence of agents are of Aspergillus genus, with Aspergillus
fungal invasion into the paranasal mucosa and flavus being most commonly implicated.
adjacent tissues is often seen.
Clinical diagnosis
Microscopic features include evidence of fungal
Imaging features invasion, noncaseating granulomas with giant
Intrasinus and extrasinus imaging features are cells, plasma cells, central small granulomas con-
mostly similar to the acute counterpart. However, taining eosinophils, fibrinoid necrosis, fibrosis, and
there is a difference in the pattern of calcifications vasculitic changes.
between acute and more chronic diseases. On CT,
intrasinus calcifications in an acute stage show Imaging features
fine punctate appearance. With a protracted The imaging features are nonspecific and similar to
course of the disease, more calcium metabolites other invasive fungal sinusitis. There is soft tissue
are deposited in the fungal mass, taking on a opacification of the involved sinus, and evidence
more dense and coarse appearance.27 Otherwise, of surrounding tissue invasion. Extension to soft
in keeping with its invasive nature, localized tissues around the sinuses and the orbits and
erosive changes in the sinus walls are seen with intracranial compartment is also seen. Typically,
extension into adjacent tissues (Fig. 6). Extension only one or two sinuses are involved. Sinus expan-
to the orbits and intracranial compartments is sion is uncommon. Bone erosion is localized to the
seen. area of extrasinus extension and extrasinus
component of the disease tends to be more exten-
sive than intrasinus component.28

Treatment and prognosis


Surgical resection is the mainstay of treatment. If
surgical intervention is not initiated in a timely
manner, the disease can invade adjacent struc-
tures, resulting in worse prognosis. Concurrent
antifungal agents are usually used to lower relapse
rate.2

SUMMARY
Fungal sinusitis is classified into the noninvasive
(AFS, fungal ball) and invasive (acute invasive,
chronic invasive, and chronic granulomatous)
forms. These different types and subtypes of
Fig. 6. Suspected chronic fungal sinusitis in a 61-year- fungal sinusitis present with clinical features
old man with symptoms of chronic sinusitis. Axial non- similar to the viral and bacterial forms of sinusitis.
contrast CT scan demonstrates mixed-attenuation However, the associated morbidity and mortality
material filling the right sphenoid sinus. Note the of fungal sinusitis is worse when compared with
focal dehiscence of the right carotid canal. the other pathogens. The radiologist based on
8 Raz et al

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Such accurate assessment by the radiologist, 2001;111(6):1006–19.
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therefore the overall prognosis of the patient. [in French].
17. Mukherji SK, Figueroa RE, Ginsberg LE, et al.
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