Isolated sphenoid sinus fungus ball: a retrospective study conducted at a tertiary care referral center in Korea.

Fungus ball (FB) is the most common form of extramucosal fungal rhinosinusitis involving one or more paranasal sinuses. The sphenoid sinus is an uncommon site of this disease. Here, we present our 20-year experience of managing isolated sphenoid sinus FB (SSFB). We retrospectively reviewed a series of 47 cases of isolated SSFB encountered between 1996 and 2015 with reference to the chronological incidence, demographics, clinical features, radiological findings, treatment modalities, and outcome. Recently, the number of patients with isolated SSFB has increased markedly. The mean age of the patients in this study was 63.1 years (range 26-84 years), and there was significant female predominance. The most common symptom was headache (72.3%), which was localised in various regions. On the other hand, nasal symptoms presented at a relatively low rate. On computed tomography, the most common findings were total opacification, calcification, and sclerosis of the bony walls. There was no significant difference in the presence of SSFB between the ipsilateral and contralateral sides of the nasal septal deviation and concha bullosa. Magnetic resonance imaging demonstrated an isointensity on T1-weighted images and marked hypointensity on T2-weighted images. Treatment consisted of endonasal endoscopic sphenoidotomy with complete removal of the FB. The prognosis was good, with no recurrence after a mean follow-up of 13.2 months. Isolated SSFB is a rare disease, but its prevalence is increasing. Although the clinical presentation is usually vague and nonspecific, SSFB should be considered in patients with unexplained headache, especially in elderly women. Endoscopic sphenoidotomy is a reliable treatment with low morbidity and recurrence rates.

Fungal Mycotic Aneurysm of the Internal Carotid Artery Associated with Sphenoid Sinusitis in an Immunocompromised Patient: A Case Report and Review of the Literature.

In immunocompromised patients, invasive molds such as Aspergillus and Mucor can lead to locally aggressive angioinvasive infections that are often life-threatening. A particularly devastating complication is the development of a fungal mycotic aneurysm resulting from invasion of the arterial wall. Due to anatomic contiguity, the sphenoid sinus provides potential access for these fungi, which often colonize the respiratory sinuses, into the cavernous sinus and internal carotid artery (ICA), thus leading to the formation of ICA aneurysms. The ideal treatment of fungal ICA aneurysms includes a combination of surgical debridement and long-term effective antifungal therapy, but the role of endoscopic resection and the duration of antimicrobials are poorly defined. Here, we present the case of a 71-year-old immunocompromised patient who developed an ICA mycotic aneurysm, associated with a proven invasive fungal infection (presumptively Mucorales) of the sphenoid sinuses, as defined by EORTC/MSG criteria, and who survived after undergoing coil embolization with parent vessel sacrifice of the aneurysm in combination with liposomal amphotericin B. We also review the literature for published cases of invasive fungal sphenoid sinusitis associated with mycotic aneurysms of the ICA and provide a comparative analysis .

Sphenoid sinus fungus ball by filaments of actinomycetes and Aspergillus fumigatus.

We present a case of sphenoid sinus fungus ball caused by Aspergillus fumigatus associated with actinomycosis. This case represents the first known reported infection caused by this rare association.

Persistent Severe Headache After Removal of Fungus Ball From the Sphenoid Sinus: A Case Report.

OBJECTIVE: Granulomatous invasive fungal sinusitis (GIFS) is a rare and life-threatening disease, whereas fungus ball (FB) is the most common form of noninvasive fungal sinusitis. Both GIFS and FB primarily develop in immunocompetent patients, with the former associated with higher mortality and morbidity. METHODS: A chart review and review of the literature. RESULTS: We present the case of a 77-year-old woman with mixed fungal sinusitis who was successfully treated with voriconazole. CONCLUSIONS: GIFS and FB can coexist in extremely rare cases, known as mixed fungal sinusitis; however, the diagnosis and subsequent treatment of mixed fungal sinusitis can be delayed because of a lack of awareness of the underlying concept. Therefore, it is crucial for clinicians to recognize the concept of mixed fungal sinusitis.

A retrospective analysis of 29 isolated sphenoid fungus ball cases from a medical centre in Korea (1999-2012).

BACKGROUND: Isolated sphenoid sinus disease (ISSD) is rare. Fungus ball (FB) is the third most common ISSD. We analysed the characteristics of isolated sphenoid FB based on demographic data, presenting symptoms, preoperative computed tomography (CT), magnetic resonance imaging (MRI), and treatment outcomes. METHODOLOGY: From 1999 to 2012, 29 patients were identified with isolated sphenoid FB. Demographic data; clinical characteristics; endoscopic, CT, and MRI findings and treatment outcomes were retrospectively analysed. RESULTS: The most common symptom was headaches, which were localized in various regions of the brain. Other symptoms were uncommon. The most common CT findings were sclerosis, calcification, enlarged sinus and total opacification. On T2-weighted MRI images, we most commonly observed signal void. Endoscopic transnasal paraseptal sphenoidotomy was performed in all patients, and for most, this was performed under local anaesthesia. No recurrence was observed in any patient. CONCLUSION: Isolated sphenoid FB is predominantly observed in older women, and it is characterised by headaches and sclerosis of the sinus wall observed on CT scans. In cases of isolated sphenoid FB, endoscopic transnasal paraseptal sphenoidotomy can be successfully performed under local anaesthesia, which may facilitate rapid recovery and a low morbidity rate.

Sphenoid sinus fungall ball: a retrospective study over a 10- year period.

A fungal ball consists of a dense conglomerate of fungal hyphae growing at the surface of the sinus mucosa without tissue infiltration. The maxillary sinus is by far the most commonly involved paranasal sinus cavity followed by the sphenoid sinus. The present study is a retrospective study of 25 consecutive cases treated during the last 10 years in the two hospitals be- longing to the Catholic University of Louvain (CHU Mont-Godinne and UCL Saint Luc). We report the symptomatology, the imaging and discuss the different surgical managements. We conclude that the clinician must have a high index of suspicion when dealing with a unilateral rhinosinusitis persisting despite a maximal and well conducted medical treatment. This is particularly so in elderly women when associated with facial pain and post nasal drip, particularly when the computed tomography shows an unilateral opacity of the sphenoid sinus with or without a sclerosis or an erosion of the bony walls, a polyp in the sphenoethmoidal recess or a hyperdensity mimicking a foreign body. An endonasal endoscopic sphenoidotomy is the treatment of choice in most cases, allowing good ventilation of the sinus and radical removal of all the fungal concretion. A biopsy of the sinus mucosa adjacent to fungal elements is of upmost important to confirm the non- invasiveness of the fungi within the tissue. Antifungal medication is not required in uncomplicated forms. All host factors producing some degree of immunosuppression must be corrected when present and must alert the clinician to rule out any forms of invasive disease.

Bilateral Orbital Apex Syndrome Related to Sphenoid Fungal Sinusitis.

Orbital apex syndrome (OAS) is a rare condition that usually occurs due to damage to surrounding inner and surrounding bone tissue. Orbital apex syndrome may result from a variety of conditions that cause damage to the superior orbital fissure and to the optic canal leading to optic nerve (II) dysfunction. We recently experienced a rare case of sphenoidal Aspergillosis, which damaged the adjacent cavernous sinus structures and led to the definite symptom of bilateral OAS in a 77-year-old male. We present this rare case with a brief review of these disease's entities.

Stereotactic drainage of empyema of the cavum septi pellucidi et vergae.

BACKGROUND: Persistent midline ventricular cavae may only rarely cause clinical symptoms. Exceptionally, empyemas may develop in these cavae. Optimal treatment has been defined only poorly so far. METHODS: Here, we report successful treatment of a bacterial empyema in the cavum septi pellucidi et vergae due to sphenoid sinus sinusitis in a 36-year-old woman by stereotactic puncture and drainage of the empyema and long-term administration of antibiotics. RESULTS AND CONCLUSIONS: Stereotactic puncture and drainage accompanied by antibiotic therapy result in beneficial outcome in the long term. Transcallosal interhemispheric approaches and free-hand techniques should be discouraged since, according to previously published reports, they may result in severe morbidity or mortality in this condition.

Isolated sinonasal posttransplantation lymphoproliferative disorder: a clinical and radiographic invasive fungal sinusitis look-a-like.

Posttransplantation lymphoproliferative disorder (PTLD) is a known complication of solid organ transplantation with chronic immunosuppression. We present a unique case that illustrates PTLD mimicking invasive fungal sinusitis both clinically and radiographically. This report addresses the critical diagnostic evaluation and management of PTLD arising from the paranasal sinuses.

[The giant fungal body in the sphenoidal sinus and the destruction of the skull base].

The objective of the present study was to estimate the efficacy of the optical systems with the variable visual field angle applied for the endoscopic interventions on the paranasal sinuses. The authors report a clinical observation of the patient presenting with the giant fungal body in the sphenoidal sinus responsible for the partial destruction of the bone canal of the optic nerve and the internal carotid artery. The patient was treated by endoscopic shenoidotomy through the paraseptal approach with the use of a sinuscope with the variable visual field angle. It was shown that the use of optical devices with the variable visual field angle makes it possible to significantly reduce the duration of the surgical intervention, facilitates orientation in the difficult-of-access regions , and ensures adequate control during the removal of neoplasms at the basis of the skull.

[Fatal sino-orbital aspergillosis in an immunocompetent case]. / Immün kompetan bir olguda fatal seyirli sino-orbital aspergilloz.

The paranasal sinus infections caused by Aspergillus spp. are usually presented clinically with mild symptoms, however they may lead to invasive disease and mortality especially in immunocompromised individuals. In this report a fatal case of sino-orbital aspergillosis developed in an immunocompetent patient has been presented. Seventy-four years old female patient was admitted to the hospital with the complaints of fever and progressively increasing headache that continued for 15 days. Due to the development of nausea, vomiting, loss of consciousness and stiff neck in the following days, cerebrospinal fluid (CSF) sample was obtained. Direct microscopic examination of the Gram and acidfast staining of the CSF sample revealed no microorganisms, no growth was detected in CSF culture and PCR amplification was negative for Herpes simplex virus and Mycobacterium tuberculosis. Since no response was achieved by empirical ceftriaxone, ampicillin and conventional anti-tuberculosis treatment and tachypnea, proptosis and progressive respiratory failure developed in the patient, she was transferred to the intensive care unit. The radiological examination revealed soft tissue lesion filling the sphenoid sinus, extending to the nasal cavity and suprasellar cistern, destruction of bones, dilated orbital vein, cavernous sinus thrombosis and infarction on left cerebral peduncule. Patient was operated and pus and fungus ball were aspirated from the openings of both sphenoid sinuses. Gomori methenamine silver, periodic acid-Schiff and haematoxylin-eosine staining of the operational material exhibited dichotomously branching hyphae. The patient was diagnosed as invasive sino-orbital aspergillosis based on the clinical, radiological and histopathological findings. Despite antifungal therapy and surgical debridement, the patient died. It should always be kept in mind that aspergillosis can develop in immuncompetent individuals. Delay in diagnosis and treatment may lead to fatality. Thus multidiciplinary approach is necessary for early diagnosis and successful treatment of aspergillus infections.

[Fungal sinus infection by Schizophyllum commune: Report of two clinical cases]. / Infección fúngica sinusal por Schizophyllum commune: a propósito de dos casos clínicos.

BACKGROUND: Schizophyllum commune is a basidiomycete fungus which is widely distributed in nature. Its role as responsible for disease in humans is not well known, partly due to its difficult identification. The incorporation of mass spectrometry techniques (MALDI-TOF) and molecular biology to the laboratories has allowed the description of a greater number of cases. CASE REPORT: In this paper, we present two cases in which S. commune was identified as the causative agent of disease: in the first case an immunocompetent patient suffered from chronic rhinosinusitis, and in the second one a sphenoid sinus infection was diagnosed in an immunocompromised patient. In both cases, S. commune was isolated. Its identification was possible by means of MALDI-TOF and this was confirmed in both patients by amplification and sequencing of the ITS region. CONCLUSIONS: In conclusion, S. commune should be considered a potential causative agent of fungal disease. Currently, MALDI-TOF and sequencing techniques are necessary for its identification.

Characteristics of isolated sphenoid sinus aspergilloma: report of twelve cases and literature review.

OBJECTIVES: Isolated sphenoid sinus aspergilloma (ISSA) is a form of fungal sinus infection that is distinct from allergic fungal sinusitis, invasive fungal disease, and Aspergillus granulomas. In this study, we identify the characteristics of patients with ISSA to achieve timelier intervention for this easily neglected disease. METHODS: In a retrospective study of patients with ISSA in our institution (1995 to 2006), 12 were identified. RESULTS: Sixty-seven percent of our patients were more than 50 years of age, and a female preponderance was noted. Headache and postnasal drip were the two most common symptoms, and the samples from 78% of our patients with postnasal drip were blood-tinged. Computed tomographic scanning provided a sensitivity of 64%, whereas endoscopic examination failed to identify abnormalities in any patients. CONCLUSIONS: Four characteristics were identified in the diagnosis of ISSA: female; usually above 50 years of age; with postnasal drip (especially blood-tinged); and headache (particularly periorbital or retro-orbital).

Sphenoid sinus aspergillosis simulating pituitary tumor in immunocompetent patient.

Aspergillosis of the sphenoid sinus is rare in immunocompetent patients. It may be mistaken for a sellar region tumor. A 65-year-old, human immunodeficiency virus-negative man presented with a 3-week history of cranial nerve III paresis and visual deterioration. The patient had a long-term history of tobacco snuff abuse. CT scans and MRI demonstrated a space-occupying lesion of the sellar and sphenoid sinus region. Presumptive diagnosis of pituitary macroadenoma was made and the patient was operated on via a transnasal-transsphenoidal approach. After the sphenoid sinus was opened, a yellow-brownish gluey material with crumbly debris extruded and was aspirated. The dura was intact. Histopathology revealed numerous Aspergillus hyphae without tissue invasion. Postoperatively, the cranial nerve III paresis resolved in a few days and visual acuity improved. Sphenoid sinus aspergillosis should be included in the differential diagnosis of sellar region processes, even in immunocompetent patients. Early diagnosis and transsphenoidal removal provides good results without the need for systemic antifungal therapy in non-invasive aspergillosis.

Headache induced by isolated sphenoid fungal sinusitis: sinus headache?

In this article, we report a case of isolated sphenoid fungal sinusitis which only presented as headache. We review the literature of this rare but interesting lesion according to the revised 2004 IHS diagnostic criteria for "Headache attributed to Rhinosinusitis".

[Effects of voriconazole and vascular lesions in invasion of aspergillosis into the central nerve system].

We report 2 patients showing invasion of aspergillosis into the central nerve system (CNS). Patient 1, an 81-year-old woman, underwent surgery for sphenoidal sinusitis. She developed cerebral infarction with unconsciousness on 12th postoperative day. CSF examination demonstrated pleocytosis with increased protein and aspergillus antigen. She was diagnosed as having invasion of aspergillosis into the CNS, and was treated with voriconazole. Her clinical manifestations and CSF findings markedly improved. However, the effects of voriconazole gradually attenuated and she demonstrated recurrence of the cerebral infarction. After 2 months, she died of systemic aspergillosis and sepsis. Autopsy studies. Severe atherosclerotic changes with calcification were demonstrated in the bilateral carotid and basilar arteries, and many aspergillus were clustered in the vessel walls. Granulomatous inflammatory lesions with aspergillus were also demonstrated in the area surrounding the chiasm. There were no massive infarcts or bleeding in the brain, but multiple small infarcts were present. Patinet 2, a 64-year-old man, showing bilateral visual loss, was receiving treatment with corticosteroids under a diagnosis of optic neuritis. Two weeks later, he developed cerebral infarction. CSF examination showed pleocytosis with increased protein and aspergillus antigen. He was diagnosed as having invasive aspergillosis from the sphenoidal sinusitis into the CNS. He was treated with voriconazole, and unconsciousness and CSF findings improved transiently. However, he developed a recurrence of the brain infarction and pneumonia and finally died 6 months later. Treatment by voriconazole was definitely effective in both patients, but both patients died of recurrent cerebral infarction, possibly due to resistance for voriconazole, or developing multicellular filamentous biofilms. Voriconazole is recommended as the first choice of antifungal agents for aspergillosis. Aspergillus infection is strongly invasive into arterial vessels. It is important to consider the possible occurrence of cerebrovascular disease when treating invasion of aspergillosis into the CNS.

Lethal sphenoid fungal sinusitis in an immunocompromised elderly patient.

Sphenoid fungal balls are rare and typically indolent lesions, unless superinfected by bacteria or invasive to adjacent neurovascular structures. If the identification or treatment of underlying complications is delayed in an immunocompromised patient, a catastrophic outcome may result. We report the case of an elderly female patient with poorly controlled diabetes mellitus suffering from sphenoid fungal sinusitis that is complicated by cavernous sinus thrombophlebitis and carotid artery stenosis. In spite of reasonable diagnosis and therapy, the patient's general condition deteriorated and she eventually died. The clinical presentation, diagnosis, and treatment strategy are discussed.

Cavernous sinus-orbital apex aspergillus infection in a diabetic patient: A case report.

RATIONALE: Cavernous sinus-orbital apex aspergillosis is a rare but serious complication of rhinosinusitis. Pathology results are scarce, and this condition is difficult to diagnose based on clinical and radiological results. PATIENT CONCERNS: A 64-year-old woman presented with cavernous sinus-orbital apex syndrome. Axial and sagittal T1 contrast-enhanced magnetic resonance imaging (MRI) showed a right orbital apex mass abutting the right posterior ethmoid sinus, sphenoid sinus, and cavernous sinus. DIAGNOSIS: Cavernous sinus and orbital apex aspergillosis. INTERVENTIONS: Functional endoscopic sinus surgery was performed, and a biopsy of the lesion tissue was submitted for examination, which showed the presence of aspergillus. OUTCOMES: One year after surgical debridement, antifungal, and anticoagulation treatments, the patient is still asymptomatic without recurrence. LESSONS: Early surgical debridement is crucial to confirm the diagnosis of cavernous sinus-orbital apex aspergillosis and prevent mortality. There is no evidence of negative effects of antibiotic and anticoagulation treatments. Despite controversy, among physicians, most opt to treat patients via anticoagulation therapy.

Scedosporium apiospermum invasive sinusitis presenting as extradural abscess.

INTRODUCTION: Chronic invasive fungal rhinosinusitis (CIFR) is a rare entity generally observed in immunodepressed subjects. The pathogen most frequently identified is Aspergillus spp. Imaging generally reveals invasive pseudoneoplastic features. We report a case of Scedosporium apiospermum (S. apiospermum) CIFR with an atypical clinical and radiological presentation. CASE REPORT: A 72-year-old immunocompetent man presented with chronic headache, neck pain and bilateral limitation of lateral gaze. Imaging revealed an isolated left sphenoidal lesion with marked bone changes and an extradural abscess over the clivus. Large endoscopic sphenoidotomy with type II rhinopharyngectomy was performed and the diagnosis of S. apiospermum CIFR was based on histological examination and fungal culture. The patient refused all medical treatment and did not present any signs of recurrence after 1 year of follow-up. DISCUSSION: S. apiospermum is a fungal species rarely isolated in CIFR. The present case was revealed by an atypical clinical presentation including isolated sphenoidal infection complicated by bilateral abducens nerve paralysis and extradural abscess. Imaging was also unusual, revealing features of fibrous dysplasia or bacterial osteomyelitis rather than the typical pseudoneoplastic appearance. The patient was successfully treated by surgery alone, which may therefore be sufficient treatment in immunocompetent subjects.