Fungal Sinusitis
Fungal Sinusitis
Fungal Sinusitis
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.
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
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.
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
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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therefore the overall prognosis of the patient. [in French].
17. Mukherji SK, Figueroa RE, Ginsberg LE, et al.
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