Isolated fronto-ethmoidal allergic fungal rhinosinusitis: case report and review of the literature.

BACKGROUND AND AIM OF THE WORK: Fungal rhinosinusitis (FRS) is a clinical entity characterized by the presence of fungi within sino-nasal cavities that may occur in patients with normal or defective immunity. Allergic fungal rhinosinusitis (AFRS) is a form of non-invasive FRS that affects patients with an abnormal immuno-mediated response to fungal antigens. This article describes a case of isolated fronto-ethmoidal AFRS. METHODS: A 20-year old male patient presented with a history of a left nasal respiratory obstruction and allergic oculorhinitis. CT scans showed a polypoid mass in the left nasal cavity and opacification of the left ethmoid sinus, frontal recess and frontal sinus with hyperdense component. The patient underwent functional endonasal sinus surgery (FESS) with removal of nasal polyps from the left nasal cavity and of cheesy-like material and dense mucus from the left ethmoid and frontal sinus. Histological examination showed presence of fungal hyphae within the allergic mucus; a diagnosis of AFRS was made. RESULTS: Follow up at 14 months showed no signs of recurrence. CONCLUSIONS: The AFRS case reported herein is characterized by isolated unilateral fronto-ethmoid involvement, a rare presentation. Endoscopic nasal treatment was effective with complete patient recovery. (www.actabiomedica.it).

Paediatric nasal polyps in cystic fibrosis.

Patients with cystic fibrosis (CF) are at increased risk of nasal polyps. We present the case of a 17-month-old Caucasian patient with CF who presented with hypertelorism causing cycloplegic astigmatism, right-sided mucoid discharge, snoring and noisy breathing. Imaging suggested bilateral mucoceles in the ethmoid sinuses. Intraoperatively, bilateral soft tissue masses were noted, and both posterior choanae were patent. Polypectomy and bilateral mega-antrostomies were performed. Histological examination revealed inflammatory nasal polyposis typical of CF. The role of early functional endoscopic sinus surgery (FESS) in children with CF nasal polyposis remains questionable as the recurrence rate is higher, and no improvement in pulmonary function has been shown. Our case, however, clearly demonstrates the beneficial upper airway symptom relief and normalisation of facial appearance following FESS in a child with this condition.

[Clinical analysis of chronic invasive fungal rhinosinusitis].

OBJECTIVE: To investigate the clinical features and treatment of chronic invasive fungal rhinosinusitis(CIFRS). METHODS: From June 2006 to August 2011, seven patients were pathologically diagnosed as CIFRS in otorhinolaryngology department of Peking university first hospital and included in this study. The clinical records were reviewed. The clinical features, clinical course, symptoms, clinical signs, CT/MRI scan of the sinuses, surgical approach, postoperative pathology and medications were analyzed retrospectively. These 7 patients received both surgical and systemic anti-fungal treatment. Among them, 2 cases with characteristically clinical features were addressed into further analyses to explore the clinical feature and treatment of CIFRS. RESULTS: Among the 7 patients, 5 were female and 2 were male. The course of diseases were from 2 months to 8 years. All patients had no systemic immune diseases and history of diabetes mellitus, while 1 case had a history of facial trauma, and another 1 case had received antibiotics for long-stay in bed after a car accident. The onset lesions of 6 cases were in unilateral maxillary sinus and 1 in unilateral ethmoid sinus. Aspergillus fungi were detected in 6 cases and mold fungi were detected in 1 case by pathology or fungal culture. After follow-up for 1-5 years, 6 patients were cured, and 1 was died. CONCLUSIONS: CIFRS are often diagnosed in patients with normal immune function. Lesions alwasys occur in single sinus, and maxillary sinus is the most commonly involved.Aspergillus is the most common pathogens. Early clinical manifestation and sinus CT images are lack of specificity. Surgery associated with adequate antifungal treatment might be the best treatment strategy.

Pediatric sinogenic epidural and subdural empyema: The role of endoscopic sinus surgery.

AIM: To analyze the indications and outcomes of open neurosurgical approaches (ONA) and endoscopic transnasal approaches (ETA) in the surgical management of pediatric sinogenic subdural and epidural empyema. MATERIAL AND METHODS: Retrospective single-center study design within a tertiary care referral center setting. Children less than 18 years of age consecutively operated on between January 2012 and February 2014 for drainage of a sinogenic subdural empyema (SE) or epidural (EE) empyema were included. MAIN OUTCOME MEASURES: success of first surgical procedure, persistent symptoms and sequelae at the end of the follow-up period. RESULTS: Nine SE (53%) and 8 EE (47%) were observed. Neurological symptoms, especially seizures, were more frequent in the SE group. Perioperative pus samples were positive in 67% of the SE group and in 75% of the EE group. The most frequently isolated bacteria belonged to the Streptococcus anginosus group. CT or MR imaging showed that most empyema probably originated from the frontal sinus. However, two cases resulted from an ethmoiditis and one case from a Pott's puffy tumor, without any direct contact with the paranasal sinus. In cases of SE, the most effective surgical technique was ONA with craniotomy. Associated endoscopic sinus drainage was useful for the purpose of bacteriological diagnosis. In cases of EE, effectiveness was noted in both ONA and ETA techniques. In two cases of EE, the ETA procedure encompassed direct drainage of the empyema through the posterior wall of the frontal sinus (Draf III approach). The number of patients successfully treated after a single surgical procedure was higher in the EE group (p=0.05). Regarding outcomes, no mortalities were observed. Persistent disorders at the end of the follow-up period, especially headaches, cognitive, concentration or schooling problems, tended to be more frequent in the SE group than in the EE group (67% vs 29%), and were more commonly observed in cases requiring several surgical procedures (75% vs 12.5%) (p=0.05). DISCUSSION: Endoscopic sinus surgery plays a critical role in the surgical management of pediatric sinogenic SE and EE. In cases of small volume EE, the endoscopic approach associated with antibiotherapy may be sufficient to treat the infectious process.

Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis.

PURPOSE: Orbital cellulitis and subperiosteal abscess (SPA) are historically associated with poor outcomes. We seek to characterize current associations with abscess formation, surgical failure and vision loss. METHODS: All cases of orbital cellulitis presenting to an affiliated hospital between April 2008 and 2013 were critically reviewed. RESULTS: Thirty patients met inclusion criteria. Average age was 28.7 ± 24.4. The male to female ratio was 2:1. Abscesses were identified in 56.7% of patients. Adults were less likely than children to present with abscesses (28.6% vs. 81.3%, p = 0.008). Of the other factors analyzed, only antibiotic use before admission (70.5% vs. 23.1%, p = 0.03) and maximum restriction (-2.5 ± 1.2 vs. -0.9 ± 0.7, p = 0.008) were associated with SPA. Temperature at presentation (37.9 ± 0.9 vs. 37.1 ± 0.4, p = 0.04), relative proptosis (5.8 ± 3.3 mm vs. 2.1 ± 1.1, p = 0.002) and abscess volume (4.3 ± 1.3 mm(3) vs. 0.7 ± 0.5 mm(3), p = 0.0004) were associated with progression to surgery. Reoperation was required in 26.7% of patients. Of these, two-thirds had combined superior/medial abscesses that re-accumulated after isolated endonasal surgery. Two of the 3 patients with profound vision loss had a dental etiology. CONCLUSIONS: Only young age, prior antibiotics and degree of restriction predicted the presence of an abscess. Re-accumulation was more common than anticipated, and drainage of superior/medial abscesses by endoscopic surgery alone had the strongest association with surgical failure. Patients with odontogenic abscesses must be treated with particular caution.

Orbital necrotizing fasciitis and osteomyelitis caused by arcanobacterium haemolyticum: a case report.

The facial region is infrequently affected by necrotizing infections. Orbital necrotizing infections are even rarer, seen following trauma, local skin infection, and sinusitis. The authors report a unique case of orbital necrotizing fasciitis and osteomyelitis resulting from Arcanobacterium Haemolyticum ethmoid sinusitis. No prior occurrences of Arcanobacterial species orbital necrotizing fasciitis/osteomyelitis have been reported.A 16-year-old boy presented to the ER with a 3-day history of fever, chills, headache, and sinus pressure. CT scan revealed soft tissue swelling of the right orbit, forehead, and ethmoid sinusitis. Within 24 hours of admission, he suffered rapidly progressive swelling and erythema of the right orbit and forehead with diminished visual acuity, despite broad-spectrum antibiotics. Orbital exploration revealed frankly necrotic fascia and periosteum along the superior aspect. Lateral canthotomy, cantholysis, decompression of the optic nerve, and soft tissue debridement with bone biopsy was performed. Operative specimens isolated Arcanobacterium Haemolyticum. Pathologic examination revealed right orbital osteomyelitis.

[The 'black turbinate sign' in a case of rhinocerebral mucormycosis]. / Signo del cornete negro en un caso de mucormicosis rinocerebral.

TITLE: Signo del cornete negro en un caso de mucormicosis rinocerebral.

[Aspergillus ethmoiditis associated with orbital abscess]. / Ethmoïdite aspergillaire compliquée d'un abcès orbitaire.

The authors report a case of Aspergillus ethmoiditis associated with an orbital abscess, diagnosed in an immunocompetent 6-year-old child, this is a rare infection and diagnosis is difficult, cause of a delayed treatment and frightening prognosis. Mycoses have emerged as important infections in clinical practice; this phenomenon is explained by the ever-growing number of immunocompromised patients and the increasing number of people traveling in areas where fungal diseases are endemic. Surgery with mycological and anatomopathologic examination can suggest a fungal infection confirmed by culture and contribute to institute adequate treatment.

[Diagnosis and management of the acute attack of sphenoid and ethmoid fungal ball sinusitis].

OBJECTIVE: To improve the diagnosis and treatment of the acute attack of sphenoid and ethmoid fungal ball sinusitis based on the analysis of clinical features. METHOD: Eighteen patients with sphenoid and ethmoid fungal ball sinusitis were reviewed, and the main symptoms included headache and fever during acute attack. Endoscopy, nasal CT and MRI can provide useful information for diagnosis. Endoscopic sinus surgery was performed on thirteen patients after drug therapy, while the other 5 patients chose conservative therapy. RESULT: The pathological examination confirmed the fungal lesions and the 13 patients had a good recovery. The result of CT and MRI scanning had a good accordance with the intra-operative findings. One patient receiving conservative treatment had acute attack again 2.5 months later, and antibiotics and topical nasal drugs improved the symptoms. CONCLUSION: Clinical presentation and radiological imaging contribute to the differential diagnosis of the acute attack of sphenoid and ethmoid fungal ball sinusitis, then the targeted therapy can be taken.

Unilateral proptosis in a 60-year-old man.

A 60-year-old immunocompromised patient developed rapidly progressive proptosis that was secondary to mucormycosis. This life-threatening fungal infection usually is associated with chemosis, proptosis, ophthalmoplegia, and visual loss. The fungus may invade ocular structures, sinuses, and extend into the brain. The standard of care includes correction of the underlying condition, administration of liposomal amphotericin B with posaconazole, and surgical debridement of infected and necrotic tissue. We present a case of unilateral proptosis due to mucormycosis in an immunocompromised patient. The patient was successfully managed medically without exenteration. The indications for exenteration are currently unclear, and no clinical guidelines exist.

Actinomycosis of the paranasal sinus.

OBJECTIVE: To report clinical characteristics and treatment outcomes of actinomycosis of the paranasal sinus. STUDY DESIGN: Retrospective review. SUBJECTS AND METHODS: The medical records of six patients with actinomycosis of the paranasal sinus between 1998 and 2006 were analyzed. RESULTS: There were no immunocompromised patients and all lesions were unilateral. Only one patient had a history of an oroantral fistula due to facial trauma. On CT scan, all patients had unilateral opacification of the maxillary sinus with focal calcified densities. All cases underwent endoscopic sinus surgery followed by relatively short-term antibiotic administration, and there was no recurrence. CONCLUSIONS: Chronic unilateral maxillary sinusitis, a calcified density in the involved sinus on radiological studies, and unresponsiveness to antibiotics are characteristics of actinomycotic sinusitis. Surgical removal of the involved tissues and the restoration of sinus ventilation seem to be important factors for treating the disease.

Ethmoid sinus mycology of chronic rhinosinusitis.

This goal of this study was to demonstrate whether fungi were present in the ethmoid sinus in patients with chronic rhinosinusitis. Before surgery, swab specimens were collected from the middle meatus for conventional fungal cultures, and lavaged fluid was collected from the nasal cavity for fungal cultures by Ponikau's method. During surgery, tissue specimens were taken from the inferior turbinate and the anterior ethmoid sinus for conventional fungal cultures and detection of fungal DNA by polymerase chain reaction. The ethmoid sinus mucosa with coating mucus was also collected for fungal cultures by Ponikau's method. Among 53 specimens, three middle meatal specimens and 27 lavaged specimens (50.9%) grew fungi. Inferior turbinal mucosa did not grow fungi, but three ethmoid sinus specimens grew fungi by the conventional fungal culture method and by Ponikau's method. Alternaria DNA was detected in 42 inferior turbinal specimens (79.3%) and in 39 ethmoid sinus specimens (73.6%). Our study showed that although fungi were rarely cultured from the ethmoid sinus Alternaria DNA was detected in most of the ethmoid sinus mucosa.

Management of allergic fungal sinusitis with intracranial spread.

Allergic fungal sinusitis (AFS) is a form of paranasal nasal disease if not managed early often involves bone destruction and extension into the orbit and anterior skull base. We present our study of patients with AFS with intracranial, exdradural extension. This study includes our experience of 26 patients with the histological and immunological diagnosis of AFS based on findings of branching septate fungi interspersed with eosinophilic mucin and Charcot-Leyden crystals without fungal invasion of soft tissue, with intracranial extension. All had erosion of bone, which was observed on computerized tomography (CT) scans, extending intracranially and eight had disease that additionally involved the lamina papyracea. The average age of patients in this study was 25 years (range 9-46). There were 20 male and 6 female patients. All patients were immunocompetent. Skin test against aspergillin showed all patients had Type 1 hypersensitivity. All patients underwent transnasal and/or transmaxillary endoscopic approaches for debridement and eight underwent orbital decompression. No patient underwent craniotomy for removal of intracranial extradural disease. No patient had a cerebrospinal fluid leak. Postoperatively, all 26 were treated with a course of corticosteroids. The follow-up period ranged from 2 to 5 years. We conclude AFS is a unique form of fungal disease that might mimic anterior skull base and paranasal sinus tumors. Most cases can be successfully managed with transnasal and/or transmaxillary endoscopic techniques.

Microbiology of the maxillary and ethmoid sinuses in patients with chronic rhinosinusitis submitted to functional endoscopic sinus surgery.

UNLABELLED: Chronic rhinosinusitis microbiology studies show the presence of aerobe and anaerobe microorganisms, fungus and virus and their incidence vary according to each study. These studies guide us on choosing the most adequate antimicrobial agent to eliminate the infectious process, thus, helping in restoring rhinosinusal mucosa. STUDY DESIGN: Clinical prospective. AIM: This work aimed at studying the microbiology of the maxillary and/or ethmoid sinuses of patients with chronic rhinosinusitis and with indication of functional endoscopic sinus surgery. MATERIALS AND METHODS: During surgery, we collected secretion and/or fragments of maxillary and/or ethmoid sinus mucosa from 41 patients to perform Gram stain, fungus direct research, aerobe and anaerobe microorganism culture and fungus culture. RESULTS: We identified the presence of aerobe microorganisms in 21 patients (51.2%), anaerobe microorganisms in 16 (39%) and fungus in 1 (2.4%). In the studied population, only 12 patients (29.2%) presented microorganisms considered pathogenic when analyzed together with the semi-quantitative leukocyte count. Staphylococcus coagulase-negative and Staphylococcus aureus were the most frequent microorganisms found, in 5 (12.18%) and in 4 (9.75%) patients respectively. CONCLUSION: This study reveals that Staphylococcus coagulase-negative and Staphylococcus aureus were the most frequent microorganisms isolated from patients with chronic rhinosinusitis.

Microbiologia dos seios maxilar e etmoidal em pacientes com rinossinusite crônica submetidos à cirurgia funcional endoscópica dos seios paranasais / Microbiology of the maxillary and ethmoid sinuses in patients with chronic rhinosinusitis submitted to functional endoscopic sinus surgery

Estudos da microbiologia da rinossinusite crônica mostram a presença de microorganismos aeróbicos, anaeróbicos, fungos e vírus e sua incidência varia de acordo com cada estudo. Estes estudos nos guiam para a escolha do antimicrobiano mais adequado para eliminar o processo infeccioso, ajudando a restaurar a mucosa nasossinusal. FORMA DE ESTUDO: Clínico prospectivo. OBJETIVO: O objetivo deste trabalho foi estudar a microbiologia dos seios maxilar e/ou etmoidal de pacientes com rinossinusite crônica e com indicação de cirurgia funcional endoscópica dos seios paranasais. MATERIAIS E MÉTODOS: Durante a cirurgia coletamos, em 41 pacientes, secreção e/ou fragmento de mucosa dos seios maxilar e/ou etmoidal para realização de bacterioscopia, pesquisa direta de fungos, cultura para microorganismos aeróbios, anaeróbios e fungos. RESULTADOS: Identificou-se a presença de microorganismos aeróbios em 21 pacientes (51,2 por cento), anaeróbios em 16 (39 por cento) e fungos em 1 (2,4 por cento). Na população estudada, apenas em 12 (29,2 por cento) o microorganismo isolado foi considerado patogênico quando analisado junto à contagem semiquantitativa de leucócitos. O Staphylococcus coagulase-negativo e o Staphylococcus aureus foram os microorganismos mais freqüentes, em 5 (12,1 por cento) e em 4 pacientes (9,75 por cento) respectivamente. CONCLUSÃO: Este estudo revela que o Staphylococcus coagulase-negative e o Staphylococcus aureus foram os microorganismos mais freqüentes isolados nos pacientes com rinossinusite crônica.

[Imaging of rhinocerebral mucormycosis]. / L'imagerie dans la mucormycose rhinocérébrale.

PURPOSE: Rhinocerebal mucormycosis is a rare life threatening fungal infection observed in immunocompromised patients. We report six cases of patients with rhinocerebral mucormycosis confirmed histologically. Our study confirms the necessity of early diagnosis when clinical and CT findings are suggestive. MATERIALS AND METHODS: This is a retrospective study including 6 diabetic patients (3 women and 3 men) aged from 28 and 63 years. Five patients had ethmoiditis evolving for a few days (3 to 5 days), and one patient was in an ketoacidotic coma and had a severe infectious syndrome with purulent rhinorrhea evolving for 4 days. All of our patients underwent computed tomography (CT) scan of the paranasal sinuses. MRI was performed in two patients with neurological findings. RESULTS: Unilateral ethmoido-maxillary sinusitis was noted in 5 cases. Only one case of pansinusitis was found. All patients presented orbital involvement. Cerebral involvement was noted in 4 cases (cerebral venous thrombosis: 2 cases; abscess: 2 cases; cerebral ischemia: 2 cases). The diagnosis of mucormycosis was based on endonasal biopsy. When available, MRI allowed a more precise evaluation of the orbital and cerebral extension. CONCLUSION: Mucormycosis is an opportunist mycosis due to mucoralis fungus. It is very invasive with a highly aggressive potential in diabetic or immunocompromised patients. Imaging study particularly CT scan, plays an important role in diagnosis especially to evaluate cerebral extension.

The role of nasal cavity disinfection in the bacteriology of chronic sinusitis.

OBJECTIVES: Several factors may influence the results of bacteriological studies in chronic rhinosinusitis. We investigated the potential role of nasal cavity disinfection in the bacteriology of the bulla ethmoidalis in patients suffering from chronic sinusitis. MATERIAL AND METHODS: Bacteriology of the bulla ethmoidalis was studied in 176 consecutive adult patients presenting a chronic sinusitis refractory to standard medical treatment who underwent functional endoscopic sinus surgery. Two different techniques were used: (A) a technique with nasal vestibule and facial disinfection with chlorhexedin (N = 89 patients and 165 samples) vs. (B) a technique with facial, nasal vestibule and nasal cavity disinfection with a povidone-iodine solution followed by a cleansing of the nasal cavity (N = 87 patients and 166 samples). RESULTS: Culture rate was 89.6% (183 bacterial isolates) for technique (A) vs 76.5% (164 bacterial isolates) for technique (B) (p < 0.001). Major bacteria encountered in the (A) group and in the (B) group were respectively: Coagulase Negative Staphylococcus: 77 vs 40 isolates (p < 0.001); Coagulase positive Staphylococcus: 44 vs 30 isolates (p = 0.061); Streptococcus pneumoniae: 4 vs 5 isolates; Others: Streptococcus sp.: 12 vs 16 isolates; Haemophilus influenzae: 8 vs 6 isolates; Enterobacteriacea: 33 vs 53 isolates (p = 0.013) and others Gram Negative Bacilli: 3 vs 7 isolates. CONCLUSIONS: The standard (A) technique to study the bacteriology of the bulla ethmoidalis in patients with chronic sinusitis yielded a higher percentage of positive culture and of bacterial isolates than a more advanced (B) technique. This is mainly due to the higher percentage of contaminant bacteria such as Coagulase Negative Staphylococcus recovered with the standard technique. Enterobacteriacea and others Gram Negative Bacilli were more often encountered into the bulla ethmoidalis with the technique where disinfection of the nasal cavity was performed.