fungal sinusitis1
TRANSCRIPT
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Fungal SinusitisDEPARTMENT OF E.N.T
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Fungal Sinusitis
Invasive Fungal Sinusitis.(Fulminantsinusitis)
Chronic invasive Sinusitis.
Fungal Ball.
Saprophytic
Allergic fungal Sinusitis.
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Fungal Sinusitis
Classification Immunologicalstatus
Prognosis Treatment
Invasive compromised Guarded Reversal ofimmunocompramise,Surgery, antifungaltreatment
Chronicinvasive
Normal Good Surgery, antifungalagents
Fungal ball Normal Good Surgery
Saprophytic Normal Good Removal
Allergic FungalSinusitis Atopic Good Surgery , Steroids,antifungal drugs
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Invasive Fungal Sinusitis
Invasive fungal Sinusitis is almostconfined to patients with altered hostdefenses, such as
Diabetic patients. Undergoing transplantation ( Bone
marrow, liver, Kidney and so on)
Leukemia. Primary or acquired immunodeficiency.
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Fungal Species
Mucormycosis : Order Mucorales
Class Zygomycetes
species Rhizopusoryzae
Aspergillosis Aspergillus flavus
Aspergillus fumigatus
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Invasive fungal Sinusitis
Mucormycosis
Obliterative invasion.
Aspergillosis
angioinvasive
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Clinical Features
Fever.
Symptoms of sinusitis ,
Orbital swelling,
Facial pain and nasal congestion
Anterior rhinoscopy, necrosis of nasalmucosa and edema.
Anesthesia of nasal mucosa and cheek. There may be invasion through hard
palate.
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Diagnosis
DNE
C.T. Scan.
M.R.I
Biopsy with special fungal stains. Culture with special fungal stains such as
calcoflour white.
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C.T.Scan
Metallic density area isseen in the maxillaryantrum . This is dueto crystallization of
calcium salts withinthe mycotic mass.
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C.T.SCAN
High-and low-densityareas are noticedinside the leftmaxillary sinus. This
gives a high index ofsuspicion for a fungalinfection.
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M.R.I
MRI findings are related to inspissated secretions.
A T1-weighted image through the opacified sinus showsmucosal thickening with isointense signal that increasedwith contrast and a non-enhancible hypointense lumen.
Proton density and T2-weighted images demonstrate a
low-signal-intensity region bridging the sinus cavity. Normal mucous and bacterial secretions have high signal
intensity related to the high water concentration.
The low-signal regions are related to the fungal infectionand dehydrated inspissated mucous, calcifications, and iron
salt deposition
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PAS
PAS (periodic acid-Schiff) stain of sinuscontent showsseptated hyphae
branching at 45degrees characteristicof aspergillosis.
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Mucor
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Aspergillus
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Treatment
Reversal of underlying predisposingconditions.
Systemic antifungal therapy.
Surgical debridement.
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Antifungal therapy
Systemic amphotericin B at I.V dosage of0.8 to 1.5 mg/kg/day to total dose of upto 3g.
Nephrotoxicity Fever, chills, nausea and hypotention.
These complications can be reduced or
eliminated with the use amphotericine Blipid complex.
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Other drugs
Itraconozole (Argillosis )
Voriconozole.
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Chronic Invasive fungal Sinusitis
Aspergillus flavus.
Aspergillus fumigatus.
Immunocompetent patients present with
pain less proptosis.
Indolent fungal sinusitis, with extention toorbit or palate
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Diagnosis
Biopsy .
Histologic picture is a granuloma in whichgiant cells contain hyphae.
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Complications
Blindness.
Cerebral extention.
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Treatment
Surgical exenteration.
Systemic anti fungal therapy.
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Fungus Balls
Fungus balls (Mycetoma) are common andgrow in the wet , moist cavities of thepara nasal sinuses, irrespective of the
immunological status of the host. Asymptomatic.
Cause symptoms indistinguishable fromchronic sinusitis.
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Fungal species
A.flavus.
A.fumigatus.
Alternaria and mucor.
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Histology
Tangled hyphae charectoristic of fungusballs
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Treatment
Conservative surgical removal byendoscopic surgical techniques.
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Saprophytic Fungal infection
Saprophytic Fungal infections occur whenubiquitous fungal spores land andgerminate on mucus crusts which fail to
clear the sinonasal cavity. Commonly seen after sinonasal surgery.
Treatment removal of crust
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Allergic Fungal sinusitis
Patients with AFS are atopic with nasalpolyps.
One third may have asthma.
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Fungal species
The majority of fungal species aredematiaceous (darkly pigmented).
Alternaria.
Bipolaris Curvularia
Aspergillus
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Allergic Fungal sinusitis
Bony erosiosn is common on sinus C.TScan.
Inspissated mucus causes heterogeneous
soft tissue density. Diagnosis is made histopathologically by
noting allergic mucin characterized byinflammatory cells,
Eosinophills and
Charcot leyden crystals ( a by product ofeosinophil degranulation)
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Allergic Fungal sinusitis
In this allergic mucin hyphal elements arebest appreciated with fungal stains.
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Treatment
Conservative non mutilating removal ofpolyps and inspissated allergic mucin byFESS.
Systemic steroids prednisone 60mg/dayfor several days and tapered off over 2-3weeks.
Endoscopic debridement.
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Immunology
Increased IgE and IgG to the specificfungus.
Increase in Serum IgE level.
As allergic fungal sinusitis causes increasein IgG and IgE,
Immunotherapy is helpful as it induces a
specific IgG blocking antibody
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Cavernous sinuses The cavernous sinuses are
irregularly shaped,trabeculated cavitieslocated at the base of theskull.
The cavernous sinuses are
the most centrally locatedof the dural sinuses and lieon either side of the sellaturcica.
These sinuses are justlateral and superior to the
sphenoid sinus and areimmediately posterior tothe optic chiasma,
.
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The cavernous sinuses
The cavernous sinusesreceive venous bloodfrom the facial veins(via the superior andinferior ophthalmic
veins) the sphenoidand middle cerebralveins.
The cavernous sinusesempty via the superior
petrosal sinuses, intothe inferior petrosalsinuses, then into theinternal jugular veinsand the sigmoidsinuses
.
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The cavernous sinuses
This complex web ofveins contains novalves;
Blood can flow in anydirection depending
on the prevailingpressure gradients.
Since the cavernoussinuses receive bloodvia this distribution,
infections of the faceincluding the nose,tonsils, and orbitscan spread easily bythis route
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Cavernous sinus
The internal carotid arterywith its surroundingsympathetic plexus passesthrough the cavernoussinus.
The third, fourth, and sixthcranial nerves are attachedto the lateral wall of thesinus. The ophthalmic andmaxillary divisions of thefifth cranial nerve are
embedded in the wall,
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Cavernous sinus thrombosis
Cavernous sinus thrombosis(CST) is the formation of a blood clotwithin the cavernous sinus,
The cause is usually from aspreading infection in the sinuses,ears, or teeth.
Staphylococcus aureusandStreptococcus
http://en.wikipedia.org/wiki/Cavernous_sinushttp://en.wikipedia.org/wiki/Staphylococcus_aureushttp://en.wikipedia.org/wiki/Streptococcushttp://en.wikipedia.org/wiki/Streptococcushttp://en.wikipedia.org/wiki/Staphylococcus_aureushttp://en.wikipedia.org/wiki/Cavernous_sinus -
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Cavernous sinus thrombosis
Cavernous sinus thrombosis causes
Decrease or loss of vision,
Drooping or bulging eyes,
Headaches, and paralysis of the cranialnerveswhich course through thecavernous sinus.
This infection is life-threatening and
requires immediate treatment, whichincludes antibioticsand
Sometimes surgical drainage
http://en.wikipedia.org/wiki/Cranial_nervehttp://en.wikipedia.org/wiki/Cranial_nervehttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Cranial_nervehttp://en.wikipedia.org/wiki/Cranial_nerve -
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Cavernous Sinus Thrombosis
This is one of the complication of infectionof the paranasal sinuses.
Ethmoid
Sphenoid. Frontal Sinus.
Orbital complications from these sinus
infections can cause thrombophlebitis ofthe cavernous sinus.
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Other causes
Source Disease Route
Nose and dangerarea of face
Furuncle andseptal abscess
Pharyngeal plexus
Ethmoid sinuses Orbital cellulitis and
abscess
Ophthalmic veins
Sphenoid andfrontal sinus
Sinusitis.Sinusitis andosteomyelitis offrontal bone
DirectSupraorbital andophthalmic vein
Orbit Cellulitis and
abscess
Ophthalmic veins
Upper lid Abscess Angular andophthalmic veinns
Pharynx Acute tonsilitis orPeritonsillar abscess
Pharyngeal plexus
Ear Petrositis Petrosal venoussinus
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Clinical features
Onset is abrupt with chills and rigors.
Acutely ill.
Eyelids get swollen with chemosis and
proptosis of the eye ball. III, IV, VI cranial nerves get involved
individually and sequentially causing totalophthalmoplegia.
Pupil gets dilated and fixed.
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Clinical features
Optic disc is congested and edematouscausing diminution of vision.
Sensation in the distribution of Vi
(ophtolmic branch of CNV) is diminished.
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Diagnosis
C.S.F is normal
C.T.Scan
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Angiogram
Findings may includedeformity of theinternal carotid arterywithin the cavernous
sinus, and an obvioussignal hyperintensitywithin thrombosedvascular sinuses on all
pulse sequences.
http://en.wikipedia.org/wiki/Cerebral_angiographyhttp://en.wikipedia.org/wiki/Cerebral_angiography -
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C.T.Scan
Sinus films are helpful inthe diagnosis of sphenoidsinusitis.
Opacification, sclerosis,and air-fluid levels are
typical findings. Contrast-enhanced CT
scanmay revealunderlying sinusitis,thickening of the superiorophthalmic vein, and
irregular filling defectswithin the cavernoussinus;
however, findings may benormal early in the diseasecourse.
http://en.wikipedia.org/wiki/CT_scanhttp://en.wikipedia.org/wiki/CT_scanhttp://en.wikipedia.org/wiki/Sinusitishttp://en.wikipedia.org/wiki/Sinusitishttp://en.wikipedia.org/wiki/CT_scanhttp://en.wikipedia.org/wiki/CT_scan -
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C.T.Scan
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Differential Diagnosis
Source Orbital cellulitis Cavernous sinusThrombosis
Source Commonly ethmoid
sinus
Nose, sinuses,
orbit, ear, andpharynx.
onset Slow; starts withedema of eye lidsthe inner canthuschemosis--proptosis
Abrupt with highfever and chillswith signs oftoxemia edema ofeye lids, chemosisand proptosis
Cranial nervesinvolvement
Involvedconcurrently withcompleteophthalmoplagia
Involvedindividually andsequentially.
Laterality Often involves oneeye Involves both eyes
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Treatment
I.V. antibiotics, after taking blood forculture,
Treatment of focus of infection.
Drainage of infected ethmoid andsphenoid sinus.
Anti coagulants