Fungal ball.. Clinical and radiological features DR. AHMED ALTUWAIJRI 1/5/2017

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1 Fungal ball.. Clinical and radiological features DR. AHMED ALTUWAIJRI 1/5/2017

2 Fungal Rhinosinusitis (FRS) Rhinosinusitis, is a common disorder affecting approximately 20% of the population at some time of their lives. It has been estimated to affect approximately 31 million patients (4% of adult population) in the United States each year. [1]. [1].International Rhinosinusitis Advisory Board. Infectious rhinosinusitis in adults: classification, etiology and management. Ear Nose Throat J 1997; 76: 522.

3 Fungal Rhinosinusitis (FRS) Disease is most commonly classified: Non-invasive : 1- Fungal ball (FB) 2- Allergic fungal rhinosinusitis (AFRS)

4 Invasive : Acute invasive fungal rhinosinusitis (AIFRS), Chronic invasive fungal rhinosinusitis (CIFRS), Chronic invasive granulomatous fungal rhinosinusitis (CGFRS)

5 Fungal Ball. An entangled mass of fungi with Minimal surrounding inflammatory reaction or surrounding fibrinous necrotic exudate containing fungal forms; No tissue invasion or granulomatous reaction is present.

6 Sinus fungus ball (SFB) is the most common subtype of fungus rhinosinusitis [2]. In a study from Houston, TX, Granville et al. reported noninvasive disease in >90% of patients with 72% AFRS, 23% FB [3]. 2. Eloy P, Grenier J, Pirlet A, Poirrier AL, Stephens JS, Rombaux P. Sphenoid sinus fungall ball: a retrospective study over a 10- year period. Rhinology. Jun 2013;51(2): L. Granville, M. Chirala, P. Cernoch, M. Ostrowski, and L. D. Truong, Fungal sinusitis: histologic spectrumand correlation with culture, Human Pathology, vol. 35, no. 4, pp ,2004.

7 Kathleen T. Montone et al, Fungal Rhinosinusitis: A Retrospective Microbiologic and Pathologic Review of 400 Patients at a Single University Medical Center, International Journal of Otolaryngology, 2012

8 Kathleen T. Montone et al, Fungal Rhinosinusitis: A Retrospective Microbiologic and Pathologic Review of 400 Patients at a Single University Medical Center, International Journal of Otolaryngology, 2012

9 Is it mycetoma? aspergilloma? Mycetoma is chronic local invasion of subcutaneous tissue by bacteria or fungi with the formation of sinus tract, swelling and granule. Moreover sinus fungal ball is not always caused by Aspergillus sp. Therefore, the sinus fungal ball seems to be appropriate term.

10 A. Chakrabarti, A. Das, and N. K. Panda, Controversies surrounding the categorization of fungal sinusitis, Medical Mycology, vol. 47, supplement 1, pp. S299 S308, 2009.

11 Usually present in old age group but can present early The average patient age was 55 (range 18 90) [3] there was a female to male ratio of 2 : 1. occurs in immunocompetent hosts. The disease was localized to one sinus in 97% of cases with no laterality predominance and was bilateral in 3% of cases. Mostly involve maxillary sinus (70%) then sphenoid then ethmoid. Aspergillus sp. being the most common isolate. [3] Kathleen T. Montone et al, Fungal Rhinosinusitis: A Retrospective Microbiologic and Pathologic Review of 400 Patients at a Single University Medical Center, International Journal of Otolaryngology, 2012

12 -Young-Joon Seo et al, Radiologic characteristics of sinonasal fungus ball: an analysis of 119 cases, Acta Radiologica 2011, 52:

13 - Kathleen T. Montone et al, Fungal Rhinosinusitis: A Retrospective Microbiologic and Pathologic Review of 400 Patients at a Single University Medical Center, International Journal of Otolaryngology, 2012

14 Risk factors: 1. Prior endodontic treatment of maxillary teeth. Strong association. 2. Female predominance. 3. Bacterial infection. Augment fungal growth via purulent secretions that provide valuable nutrient supplies to the fungi.

15 Cont.. air pollution, Long-term use of antibiotics and glucocorticoids, and immunosuppression and diabetes, are also thought to be related to the pathogenesis of fungal ball. However,the relationship between diabetes and fungal ball requires further investigation [4] [4]Huaming Zhu et al, CT imaging and clinical features of sinus fungus ball with bone erosion, Journal of Nature and Science, Vol.1, No.4, e69, 2015

16 Presentation Kazuhiro Nomura et al, Sinus Fungus Ball in the Japanese Population: Clinical and Imaging Characteristics of 104 Cases, International Journal of Otolaryngology,Volume 2013

17 -Young-Joon Seo et al, Radiologic characteristics of sinonasal fungus ball: an analysis of 119 cases, Acta Radiologica 2011, 52:

18 patients usually present with nonspecific symptoms of chronic rhinosinusitis and they only have one sinus cavity involved. Generally, they are less symptomatic, the disease being recurrent and resistant to proper antibiotic treatment.

19 What should call attention to the clinician are the unilateral symptoms, accompanied by eventual pain, with possible associated symptoms: purulent rhinorrhea,nasal crusting, or dysosmia/cacosmia. when the fungus ball is localized in the sphenoid sinus, headache or facial pain is frequently encountered. [3] Elena Patrascu et al, Difficulties in the diagnosis of fungal rhinosinusitis Literature review, Romanian Journal of Rhinology, Vol. 6, No. 21, January - March 2016

20 The nasal endoscopy is non-specific in most of the cases. When maxillary sinuses are involved, it is helpful to perform a sinusoscopy that may reveal a characteristic fungus ball [3] [3] Elena Patrascu et al, Difficulties in the diagnosis of fungal rhinosinusitis Literature review, Romanian Journal of Rhinology, Vol. 6, No. 21, January - March 2016

21 Radiology CT - most reliable diagnostic imaging method. There are some evocative, but not pathognomonic signs that may indicate fungal etiology [3] : presence of an image of metallic tone intrasinusally, looking like a foreign body; existence of multiple calcifications or metallic densities, areas of microcalcification; heterogeneous content, unilateral or, more rarely, across multiple sinuses; lack of areas of osteolysis or bone thinning, probably only possible because of the pressure exerted by the long fungus ball on the bony walls. [3] Elena Patrascu et al, Difficulties in the diagnosis of fungal rhinosinusitis Literature review, Romanian Journal of Rhinology, Vol. 6, No. 21, January - March 2016

22 CT features of sinus fungus ball, including an abnormal increase in the density of the sinuses, sinus mucosal thickening, calcification, sclerosis of the sinus lateral wall, and bone erosion [4]. [4] Huaming Zhu et al, CT imaging and clinical features of sinus fungus ball with bone erosion, Journal of Nature and Science, Vol.1, No.4, e69, 2015

23 The mechanism of bone erosion in association with fungus ball is unclear. However, this study suggest an association between mechanical compression by the fungal mass and prolonged disease duration ( 31.43%). Calcification is the most specific CT imaging finding of sinus fungus ball; Our data do not support a relationship between bone erosion and calcification. [4] [4] Huaming Zhu et al, CT imaging and clinical features of sinus fungus ball with bone erosion, Journal of Nature and Science, Vol.1, No.4, e69, 2015

24 In the present study, all cases of fungal ball bone erosion in the maxillary occurred in the natural ostium, and most showed expansive growth. Sinus tumor erosion on CT imaging usually manifests as irregular growth, and was frequently not limited to the sinus ostium. [4] [4]Huaming Zhu et al, CT imaging and clinical features of sinus fungus ball with bone erosion, Journal of Nature and Science, Vol.1, No.4, e69, 2015

25 Figure 1. Computer tomography image showing bone erosion(arrow) of the inner wall in a maxillary sinus (A) and a sphenoid sinus(b) fungus ball.

26 Figure 2. Computer tomography image showing a sphenoid (A) and a maxillary sinus (B) fungus ball without bone erosion.

27 Figure 1: Typical neuroimaging findings of maxillary fungus ball. (a) Coronal CT scan with soft tissue density. Left maxillary sinus is completely filled with material. High density spots are seen

Coronal T2-weighted MR image. Extremely low signal intensity to signal void indicates the presence of fungus ball. Peripheral high intensity area indicates edematous mucosa.

28 Coronal T2-weighted MR image. Extremely low signal intensity to signal void indicates the presence of fungus ball. Peripheral high intensity area indicates edematous mucosa. Kazuhiro Nomura et al, Sinus Fungus Ball in the Japanese Population: Clinical and Imaging Characteristics of 104 Cases, International Journal of Otolaryngology,Volume 2013

30 Radiological findings are the only option for preoperative diagnosis, However, it is not easy to discriminate sinonasal fungus ball from other forms of fungal or unilateral sinusitis based on radiologic findings only prior to surgery.

31 Shape of calcification Four types of calcifications were assigned on the CT scans: fine punctate, linear, nodular, and round or eggshell.

32 Location The location of the calcifications within the sinus were also categorized as : peripheral, central, mixed pattern

33 Seventy-eight (67.2%) of the 116 patients with a sinonasal fungus ball on contrast and non-contrast CT had areas suggestive of calcification. The calcifications were located centrally within the sinus in 67 (85.9%) and peripherally near the sinus wall in seven (7.7%). The shape of the intrasinus calcifications were nodular (53.8%), linear (20.5%), mixed (11.5%), round (10.3%), and fine punctate (3.8%)

34 It was difficult to discriminate between mucosal thickening and a fungal mass on non-contrast enhanced CT scans.

35 - Coronal contrast-enhanced CT scan (a) - Centrally located hyperattenuating fungal mass (small star) with nodular calcification (short arrow) - The rim appear to have an enhanced mucosal membrane (long arrow) - In the coronal non-enhanced CT scan (b)

38 Fungal masses were less frequently detected on noncontrast CT scans (27.8%) as compared to the contrast-enhanced CT scans (82.8%). This difference is due to the fact that contrast media enhances the sinonasal fungus ball along the inflamed surface of the fungal mycelia, which makes it possible to discriminate fungus balls from the surrounding structures.

40 MRI findings The inflamed mucosal lining of the paranasal sinus was hyperintense on T2-weighted images.(88.2%) The fungal masses On T1-weighted images, 35.3% of were hypointense and 47.1% were isointense; 94.1% were marked hypointense on T2-weighted images.

41 Calcifications and paramagnetic metals such as iron, magnesium and manganese were visualized as areas of signal void on T2-weighted images.

42 (c) Corresponding T2-weighted MR image with marked low signal intensity within the mass (small star). The mucosal and submucosal layers (arrow) are hyperintense due to inflammation and secretions

44 MRI is a more reliable tool for identifying a sinonasal fungus ball,but due to high cost can t be done for all patient. In conclusion, contrast-enhanced CT and MRI can improve the reliability of a preoperative diagnosis of a sinonasal fungus ball.

45 Histopathology Definitive diagnosis of a sinonasal fungus ball is made by histopathological examinations using special stains (PAS, Grocott-Gomori) revealing the presence of a high number of hyphae and mycotic colonization, confirmed by culture specimens. Only after surgery!

46 Figure 1: High power of fungus ball showing entangled masses of fungal organisms (original magnification by 200).

47 Treatment Complete removal of the lesion and adequate drainage of the sinus using an endoscope is the preferred therapeutic schedule for the treatment of SFB, with a lower recurrence rate after surgery. The fungus ball cure rate was 98.8%,

48 Refrences Kathleen T. Montone et al, Fungal Rhinosinusitis: A Retrospective Microbiologic and Pathologic Review of 400 Patients at a Single University Medical Center, International Journal of Otolaryngology, 2012 Eloy P, Grenier J, Pirlet A, Poirrier AL, Stephens JS, Rombaux P. Sphenoid sinus fungall ball: a retrospective study over a 10- year period. Rhinology. Jun 2013;51(2): L. Granville, M. Chirala, P. Cernoch, M. Ostrowski, and L. D. Truong, Fungal sinusitis: histologic spectrumand correlation with culture, Human Pathology, vol. 35, no. 4, pp ,2004. [4] Huaming Zhu et al, CT imaging and clinical features of sinus fungus ball with bone erosion, Journal of Nature and Science, Vol.1, No.4, e69, 2015 Young-Joon Seo et al, Radiologic characteristics of sinonasal fungus ball: an analysis of 119 cases, Acta Radiologica 2011, 52: [3] Elena Patrascu et al, Difficulties in the diagnosis of fungal rhinosinusitis Literature review, Romanian Journal of Rhinology, Vol. 6, No. 21, January - March 2016 Kazuhiro Nomura et al, Sinus Fungus Ball in the Japanese Population: Clinical and Imaging Characteristics of 104 Cases, International Journal of Otolaryngology,Volume 2013 A. Chakrabarti, A. Das, and N. K. Panda, Controversies surrounding the categorization of fungal sinusitis, Medical Mycology, vol. 47, supplement 1, pp. S299 S308, International Rhinosinusitis Advisory Board. Infectious rhinosinusitis in adults: classification, etiology and management. Ear Nose Throat J 1997; 76: 522.

49 Thank you!

Controversies surrounding categorization of fungal sinusitis

Controversies surrounding categorization of fungal sinusitis Arunaloke Chakrabarti Professor,Department of Medical Microbiology Center for Advanced Research in Medical Mycology Postgraduate Institute of