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Fungal sinusitis.pptx
- 1. Fungal Sinusitis BY OSAMA ALSHAAILI R2116
- 2. Outline Basics Types of fungal sinusitis Management What's new
- 3. Forms yeast or mold Yeast - Unicellular - Reproduce asexually by buddingPseudohyphae – when bud doesn’t detach from yeast Mold - Multicellular - Grow by branching – hyphae
- 4. Microscopic appearance Septated hyphae Nonseptated hyphae
- 5. Classifications Noninvasive - Fungus Ball (fungus mycetoma) - Saprophytic fungal infection - Allergic Fungal Sinusitis Invasive - Acute Invasive Fungal Sinusitis - Chronic Invasive Fungal Sinusitis - Chronic Granulomatous Invasive Fungal Sinusitis
- 6. How to differentiate ? Invasive Presence of fungal hyphae within the mucosa, submucosa, bone, or blood vessels of the paranasal sinuses Noninvasive Absence of fungal hyphae within the mucosa and other structures of the paranasal sinuses
- 7. Fungal Ball Sequestration of fungal elements within a sinus without invasion or granulomatous changes Presents similar to rhinosinusitis, Cocosmia peanut-butter like appearance Frontal/Maxillary sinus most common followed by sphenoid sinus Surgical Removal with restoration of drainage of the sinus
- 9. Saprophytic Fungal Infestation After sinonasal surgery Visible growth of fungus on mucus crusts without invasion Diagnosis: Endoscopic visualization of crusts with fungi Treatment: Weekly nasal endoscopy with removal of crusts until disease process resolves
- 10. Allergic Fungal Rhinosinusitis Most common form Hypersensitivity reaction to inhaled fungal organisms Typical allergic Mucin Diagnostic criteria (Brent &Khun) : 1) Nasal Polyps 2)The presence of eosinophilic mucin 3) Characteristic CT 4) +ve Fungal culture and/or smear 5) Fungus-specific IgE is demonstrated 6) immunocompetent
- 12. AFRS
- 13. MRI
- 14. Microscopic examination Charcot - Leyden crystals
- 15. Managment Surgical removal of allergic mucin restoration of normal sinus drainage is goal Stepwise management : - Topical Steroids - Antileukotrienes inhibitors - Antifungal - Biologics - Oral steroids - Experemental Therapies
- 16. Pre-op Steroids Pre-op Anti Fungal
- 17. High vs low volume Post-op Steroids
- 19. Future Therapeutic options aPDT (blue light therapy) Poloxamer gel Povidon iodine 10% irregation Nitric oxide releasing solutions
- 20. Acute Invasive Fungal Sinusitis Mortality 50 - 80% Typically Immunocompromised patients Two clinical populations - Poorly controlled Diabetics – ususally caused by fungi of order Zymocycetes (Rhizopus, Rhizomucor, Absidia, and Mucor) - Immunocompromised with severe neutropenia (chemotheraphy patients, BMT, organ transplants, AIDS) – Aspergillus accounts for 80% of infection in this group
- 21. Acute Invasive Fungal Sinusitis Spores inhaled = fungus grows in warm, humid sinonasal cavity Fungi invade neural and vascular structures with thrombosis of feeding vessels Mucor causes obliterative vascular invasion leading to ischemia. Necrosis and loss of sensation = acidic environment = further fungal growth Extrasinus extension occurs via bony destruction, perineural and perivascular invasion
- 22. CT scan • Unilateral ethmoid involvement with bone destruction • intraorbital spread and proptosis
- 23. MRI
- 24. Managment Aggressive surgical debridement and systemic antifungal therapy High doses of Amphotericin B (1-1.5 mg/kg/d) are recommended. Oral Itraconazole (400 mg/d) can replace once the acute stage has passed Reversal of cause of immunosuppression if possible Intracranial spread is most predictive of mortality
- 25. Chronic Invasive Fungal Sinusitis Slower disease process than acute Biggest difference: Most patients are immunocompetent Usually persistent and recurrent disease Noncontrast CT – Hyperattenuating soft tissue mass withing one or more of paranasal sinuses, bone involvement with or without sclerosis MRI – decreased signal on T1& T2
- 26. Management Similar to acute – surgical + medical Start with Amphotericin B until can rule out Mucormycosis Best length of treatment not well studied Most recommend 3-6 months of therapy Close F/U and debridement required Biopsy anything that is suspicious as asymptomatic recurrence is not uncommon
- 27. Granulomatous Invasive Fungal Sinusitis Same entity as chronic invasive fungal sinusitis Primarily found in Africa and Southeast Asia, only few case reports in US Immunocompetent Caused by Aspergillus flavus Characterized by noncaseating granulomas in the tissues
Editor's Notes
- 20,000 – 1.5 million fungal species Few dozen species cause human infection SporeReproductive structure produced in unfavorable conditions
- Assparglus septate , branching at 45 degree Mucormycosis, non septating , branch at 90 degree ==== Spores reproductive strucutre inhalation of spores – most common way fungi infiltrate sinuses to cause disease
- -Inhaled spores grow while evading host immune system (no invasion) -Congestion, facial pain, headache, rhinorrhea -Cacosmia (perception of foul odor when no such odor exists) -Mass within the lumen of paranasal sinus and is usually limited to one sinus -Antifungal medications usually unnecessary
- High density material with thickened walls of the maxillary sinus due to chronic inflammation MRI – variable T1 and hypointense T2 due to absence of free water, calcifications and paramagnetic metals also generate decreased T2 signal – no central enhancement to differentiate from neoplasm
- -Common in warm, humid climates -sensitivity resulting in chronic noninfectious inflammatory reaction - IgE type I immediate hypersensitivity and type III hypersensitivity are Involved ===== Younger individuals, third decade, immunocompetent Often associated history of atopy with allergic rhinitis or asthma Chronic headaches, nasal congestion, and chronic sinusitis for years
- Unilateral (78% of cases) Sinus expansion Bone destruction in 20% of cases More often in advanced or bilateral disease “Double Densities” Heterogeneity of signal increased heavy metal content (iron and manganese) and calcium salts
- variable T1 appearance, low T2 signal (attributed to high concentration of iron, magnesium, and manganese concentrated by fungal organisms and also due to a high protein, low free water content of allergic mucin
- Found in any esonephlic related disease These bipyramidal-shaped crystals are composed of the enzyme lysolecithin acylhydrolase, one of several eosinophilic proteins that damage respiratory epithelium and contribute to the pathology of allergy in the upper respiratory tract.
- -Beudosnide -montelukost -topical or systemic -Omaluzimab/dupilumab -
- The need for pre-operative medication, especially oral corticosteroids, in AFRS patients has been widely utilized. Pre-operative oral corticosteroids have shown a greater reduction in inflammation, radiological and endoscopic scores in AFRS when compared to CRSwNP patients.5 A meta-analysis of 1148 patients showed that pre-operative oral corticosteroids also reduced intra-operative blood loss and improved surgical field quality.6 However, it must be kept in mind that the use of these medications in the pre-operative period could impact any biopsies or mucous samples by under-staging the disease process at surgery. ============== Antifungal Agents A randomised control trial done in patients with AFRS treated with pre-operative itraconazole for 4 weeks in one arm and none in the other showed reduction in Clinical (SNOT 20), radiological (Lund Mackay) and endoscopic (Kupferberg) scores. Fifteen patients had complete resolution of disease endoscopically.7 Unfortunately, the authors did not mention the dosage used in their study. Another study comparing the efficacy of oral itraconazole (200 mg BD for 2 days followed by 100 mg BD for 26 days) in the pre and postoperative period showed better disease control and lesser chances of recurrence with pre-operative administration.8
- A comparative study between 9 post-operative patients and 3 un-operated patients comparing metered nasal spray, nebulization and nasal douching showed that douching had good penetration into the maxillary and frontal recess but not so much into the sphenoid and frontal sinuses A prospective randomised control trial with 121 patients comparing low volume high-pressure devices such as nasal sprays vs high volume, low-pressure devices showed that the latter had better reduction in the SNOT 20 scores. ========= NO RCT till now for oral steroids but A retrospective chart review of 26 patients by Kupferberg et al showed maximum improvement in the post-operative period with the use of steroids for a month after surgery. The authors found a reduction in mucosal grading scores, incidence of fungal mucin and polyps A retrospective review of 15 patients by Kinsella et al showed that all the patients on oral steroids did not have any recurrences but those needing revision surgery did not get oral steroids in the post-operative period =======
- Oral antifungals have been inadequately studied in the management of AFRS.25–27 Of the three studies in the literature, one used oral terbinafine whereas the other 2 used oral Itraconazole. There are mixed opinions about the inferences drawn from these studies but the results have limitations due to small sample sizes. One of the studies recruited 6 patients, in which 3 patients received itraconazole and 3 received placebo. The study arm group showed improvement in CT scores and reduction in eosinophil counts, while there was worsening of the same in the control group. -- Kennedy et al did a randomized control trial with high-dose oral terbinafine in 26 patients compared to a similar group on placebo and found no radiological or symptom improvement at the end of 6 weeks. ================ Topical Antifungals There were many more research studies focusing on topical antifungals compared to oral antifungals in the early 2000’s.28–41 Most of these studies used topical amphotericin B in the management of AFRS. Two meta-analysis studies eventually showed that there was no benefit with the use of intranasal amphotericin B either in the form of a rinse or nasal spray.
- Most lethal form of fungal sinusitis Rare in immunocompetent patients Present with fever, facial pain, nasal congestion, epistaxis progressing to proptosis, visual disturbance, headache, mental status changes, seizures as spread occurs Necrotic nasal septum ulcer (eschar), sinusitis, rapid orbital and intracranial spread resulting in death Angioinvasion and hematogenous dissemination common
- Nasal and palate mucosa destroyed Facial anesthesia Proptosis Cranial nerve deficits Mental status changes
- Noncontrast CT Severe unilateral nasal cavity soft tissue thickening is most consistent (but nonspecific) early CT finding Hypoattenuating mucosal thickening within lumen of paranasal sinus with rapid aggressive bone destruction of sinus walls occurs as disease progresses Unilateral involvement of ethmoids, sphenoids Intracranial extension can result in cavernous sinus thrombosis, carotid artery invasion, occlusion, or pseudoaneurysm
- MRI – better for evaluating intracranial and intraorbital extension - Evaluate for inflammatory change in orbital fat and extraocular muscles - Obliteration of periantral fat is a subtle sign of extension - Leptomeningeal enhancement progressing to cerebritis and abscess ===================== Aspergillus in left maxillary sinus with extension anterior and posterior to the retroantral space. There is diffuse involvement of the muscles of mastication
- 73% of patients with intracranial spread die Debride until clear, bleeding margins reverse DKA and improve hydration 80% survival if done promptly Absolute neutrophil count< 1000 = poor prognosis WBC transfusion and granulocyte colony stimulating factor to increase ANC
- Progression over months to years with fungal organisms invading mucosa, submucosa, blood vessels, and bony walls Does not respond to antibiotics Worsens with steroids markedly decreased signal on T2 weighted images May mimic malignancy with masslike appearance and extension beyond sinus confines IN CT
- Surgery resect all involved tissue to expose bleeding margins Systemic antifungals === chronic invasive fungal sinusitis longer clinical history (usually more than 12 weeks) 5 hyperdense material within the sinus is more common sclerotic changes to the bony walls of the affected sinuses representing chronicity of the disease
- Chronic indolent course similar to chronic invasive fungal sinusitis Presentation and work-up are exactly the same as CIFS Treatment Surgical resection to bleeding margins Topical antifungal rinses Systemic antifungals Oral voriconazole or itraconazole Minority of authors believe systemic antifungals not required