The document discusses various forms of fungal sinusitis, including allergic fungal sinusitis, chronic noninvasive fungal sinusitis, and acute invasive fungal sinusitis, detailing their imaging findings and clinical implications. Key characteristics include the involvement of multiple sinuses, the density of secretions, and potential bone erosion or expansion based on the patient's immunocompetence. Diagnostic considerations also emphasize assessing for signs of invasiveness and the patient's clinical context, particularly immunosuppression and atopy.

1. Fungal sinusitis
Imaging findings
Maria Cucos MD

2. forms
allergic (AFS)
chronic noninvasive (CNFS)
chronic invasive (CIFS)
acute invasive (AIFS)
Maria Cucos MD

3. allergic fungal sinusitis
Maria Cucos MD

4. chronic severe noninvasive form
immunocompetent, nondiabetic
atopic patient, asthma
long-standing symptoms of chronic RS
facial deformity, diplopia
serum eosinophilia, elevated IgE
Maria Cucos MD

5. CT with soft tissue and bone window best
multiple sinuses, ethmoid > maxillary
hyperdense nonenhancing material
peripheral mucosa enhances
bone expansion +/- erosion
Maria Cucos MD

6. DDX expansile sinonasal lesion
allergic fungal sinusitis
sinonasal poliposis
antrochonal polyp
mucocele
esthesioneuroblastoma
Maria Cucos MD

7. Remember
symptomatic atopic patient
increased density in multiple sinuses with bone expansion
use soft tissue window to assess density of secretions
Maria Cucos MD

8. chronic noninvasive fungal sinusitis
Maria Cucos MD

9. also called mycetoma, fungus ball, aspergilloma
immunocompetent
non-atopic
minimally symptomatic
Maria Cucos MD

10. 1 sinus, commonly maxillary
with high density mass with Ca++
which may be ovoid or conform to sinus shape
a/w chronic osteitis
fungus ball is hypo T1, hypo T2
coronal NECT best
Maria Cucos MD

11. DDX
chronic rhinosinusitis
less likely to appear mass like
affects > 1 sinus
Ca++ more rare
allergic fungal sinusitis
atopy
high density material, low T1, T2
but with bone expansion
Maria Cucos MD

12. chronic invasive fungal sinusitis
Maria Cucos MD

13. the same as chronic noninvasive fungal sinusitis
high density material + chronic osteitis
+
invasiveness of fungal mass
extrasinus extension +/- bone erosion
Maria Cucos MD

14. acute invasive fungal sinusitis
Maria Cucos MD

15. acute onset in immunosuppressed patient
spread occurs via vascular invasion
can be fatal
Maria Cucos MD

16. dense secretions
bone destruction
ill-defined spread to soft tissues
pterygopalatine fossa, masticator space, infratemporal fossa
orbit, intracranial fossa
! infiltration of fat planes can be present w/o bone erosion
via vascular channels
Maria Cucos MD

17. CECT with soft tissue and bone window
soft tissue and muscles may enhance
MRI, T1+C FS if suspected orbital and intracranial complications
leptomeningitis, epidural abscess, subdural empyema, brain abscess
MRA, MRV
arterial pseudoaneuryrsm, thrombosis, dissection + brain ischemia
cavernous sinus thrombosis
! always look at cavernous sinus, cavernous ICA, and basilar artery
with sphenoid sinusitis
Maria Cucos MD

18. DDX destructive sinonasal lesion with soft tissue involvement
acute invasive fungal sinusitis
acute rhinosinusitis
chronic invasive fungal sinusitis
granulomatosis with polyangiitis (Wegener’s)
sinonasal lymphoma
sinonasal carcinoma
Maria Cucos MD

19. Questions to ask with fungal sinusitis
is the patient immunosuppressed?
is the patient atopic?
is the patient symptomatic?
one or more sinuses involved?
Maria Cucos MD

20. Maria Cucos MD
allergic fungal sinusitis chronic noninvasive fungal sinusitis
atopy, asthma
chronic symptoms
multiple sinuses, ethmoidal +
hyperdense material
bone expansion +/- erosion
noninvasive
immunocompetent/mildly immunosuppressed
mildly symptomatic
one sinus, maxillary +
hyperdense material
osteosclerosis +/- volume reduction
noninvasive
chronic invasive fungal sinusitis acute invasive fungal sinusitis
diabetic patient
chronic symptoms
hyperdense material
osteosclerosis + bone erosions
extra-sinus invasion
immunosuppressed, diabetic
acute dramatic symptoms
hyperdense material less prominent
bone erosions, no osteosclerosis
extra-sinus invasion

21. Remember
context is important
consider AIFS in immunosupressed and diabetic patients
consider CNFS in immunocompetent patients or only
mildly immunosuppressed
Maria Cucos MD

22. Remember
always look for signs of invasive disease
soft tissue infiltration/invasion
bone destruction
Maria Cucos MD

23. Remember
consider AIFS in immunosuppressed patient
with maxillary disease + infiltrated periantral fat even if
no bone erosion is present
Maria Cucos MD