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Section 2 Inammatory Nasal Conditions112
3. Connor SE. e skull base in the evaluation of sinonasal disease: role of
computed tomography and MR imaging. Neuroimaging Clin N Am. 2015;25:
619-51.
4. Aibandi M, McCoy VA, Bazan C III. Imaging features of invasive and noninvasive
fungal sinusitis: a review. Radiographics. 2007;27:1283-96.
5. Mafee MF, Tran BH, Chapa AR. Imaging of rhinosinusitis and its complications:
plain lm, CT, and MRI. Clin Rev Allergy Immunol. 2006;30:165-86.
6. Green WH, Goldberg HI, Wohl GT. Mucormycosis infection of the cranio-facial
structures. Am I Roentgenol Radium er Nucl Med. 1967;101:802-6.
7. Reddy CEE, Gupta AK, Singh P, et al. Imaging of granulomatous and chronic
invasive fungal sinusitis: comparison with allergic fungal sinusitis. Otolaryngol
Head Neck Surg. 2010;143:294-300.
8
CHAPTER
Fungal Diseases of
Nose and Paranasal Sinuses:
Surgical Aspects
Suresh C Sharma, Kapil Sikka
• Introduction
• Classication
– Mycetoma (Fungal Ball)
– Allergic Fungal Rhinosinusitis
– Invasive Fungal Rhinosinusitis
• Clinical Characteristics
– Allergic Fungal Rhinosinusitis
INTRODUCTION
■ Fungal sinusitis is a common disease in the Indian subcontinent, and
elsewhere especially in the developing world.
■ ese are common in North and Northwest India.
■ e disease encompasses a heterogeneous spectrum.
■ Careful interpretation of clinical and radiological ndings is paramount
as management of various spectra is dierent and some drugs,
such as steroids may be treatment of choice in one form and highly
counterproductive in other.
CLASSIFICATION
■ e disease has been classied largely on the basis of immune status of
the host and the immune response to the fungus. Some overlap exists
between various subtypes.
■ e more decient the immune system, the more aggressive is the
disease.
Broadly, fungal sinusitis is classied as:
■ Noninvasive:
• Fungus balls (also called as mycetoma)
• Allergic fungal rhinosinusitis (AFRS)
– Invasive Fungal Sinusitis
– Chronic Invasive Rhinosinusitis
• Diagnosis
• Treatment
– Mycetoma
– Allergic Fungal Rhinosinusitis
– Invasive Fungal Sinusitis
Section 2 Inammatory Nasal Conditions114
■ Invasive:
• Acute invasive
• Chronic invasive (further classied into granulomatous and non-
granulomatous).1
Mycetoma (Fungal Ball)
■ is is the benign presence of “tangled mats” of hyphae in typically one
sinus.
■ Frequently detected incidentally or by vague nasal symptoms.
Allergic Fungal Rhinosinusitis
■ e disease, though common, is poorly understood.
■ e mechanisms of occurrence are presumably similar to allergic bronchopulmonary aspergillosis mediated by both type 1 [immuno globulin E
(IgE)] and type III (IgG-antigen immune complexes).
■ e disease is hence an immune response to fungi rather than direct
infection.
■ Polypi are the hallmark of AFRS disease. ere is gradual accumulation
of allergic mucin.
■ Bent and Kuhn have outlined the major and minor clinicopathologic
features for diagnosis of AFRS (Table 8.1).
2
e criteria, though not pathognomonic, are a guide to the diagnosis of
AFRS. Some, such as bone erosion have hence been modied as the same is
not a hallmark of AFRS but of invasive fungus.
Invasive Fungal Rhinosinusitis
■ e hallmark of this type of fungal infection is tissue invasion which
clinicoradiologically dierentiates it from AFRS.
■ Acute invasive rhinosinusitis is a term used for a fulminant infection
where the patient is usually immunocompromised and the time course
is less than 4 weeks. Vascular invasion is prominent histologically. Most
patients are immunocompromised.
■ Chronic invasive rhinosinusitis patients have a more protracted disease
course (more than 4 weeks) and have minimal or no vascular invasion,
and immune compromised states.
Table 8.1: Diagnostic criteria of allergic fungal rhinosinusitis (AFRS).
Major criteria Minor criteria
Evidence of type 1 (IgE-mediated) hypersensitivity Asthma
Nasal polyposis Unilateral predominance
Characteristic CT ndings Radiographic bone erosion
Eosinophilic mucus Fungal culture
Positive fungal smear Charcot Leyden crystals
Serum eosinophilia
(IgE: Immunoglobulin E; CT: Computed tomography).
CLINICAL CHARACTERISTICS
Allergic Fungal Rhinosinusitis
■ As already mentioned, AFRS is the immune-mediated hypersensitivity
to fungus.
■ e clinical features are result of accumulation of allergic fungal mucin,
consisting of eosinophils, Charcot-Leyden crystals and fungal hyphae.
e resulting expansion of sinuses leads to bone remodeling and
decalcication. Polypi, as already mentioned are universally present.
■ Sinus remodeling, can lead to orbital symptoms like proptosis and visual
loss (Fig. 8.1).
Invasive Fungal Sinusitis
■ e symptoms of acute and chronic sinusitis are largely as a result of
tissue invasion by fungus, the former being more fulminant and orid.
Since vascular invasion is key feature of acute invasive fungal sinusitis,
tissue necrosis is an early feature.
■ Fever may be seen in 50% cases and most patients present with
discoloration of cutaneous and mucosal areas of nose and palate. Since
most patients of acute invasive sinusitis are immune compromised
(diabetics being most common), features of primary disease are mostly
present (Fig. 8.2).
■ Extensive rapid spread of disease is common and patients frequently
present with symptoms of intracranial spread, cavernous sinus
thrombosis and fungal meningitis.
Chronic Invasive Rhinosinusitis
■ Generally occurs in immune competent individuals and mimics other
sinonasal disorders like sinusitis, neoplasms and granulomatosis with
polyangiitis.
■ Nasal obstruction, headache, proptosis, and visual loss are common
presenting symptoms.
■ Pain, with neuralgic characteristics is frequent and very dicult to treat.
It indicates neural invasion and a guarded prognosis.
115Chapter 8 Fungal Diseases of Nose and Paranasal Sinuses: Surgical Aspects
Fig. 8.1: Allergic fungal rhinosinusitis, right eye proptosis.
Section 2 Inammatory Nasal Conditions116
Fig. 8.2: Patient presenting with acute invasive fungal sinusitis, with blackening of skin and
surrounding edema.
DIAGNOSIS
■ Mode of diagnosis of various fungal disease subtypes is dierent.
Mycetoma and AFRS can be readily diagnosed clinicoradiologically and
tissue diagnosis is generally conrmed only after therapeutic excisions.
■ Most frequent pathogens in AFRS are the Aspergillus and dematiaceous
molds (Alternaria and Bipolaris).
■ Acute invasive rhinosinusitis, however, is generally caused by zygomycete
fungi frequently being Mucor and Rhizopus. ough clinically evident
in most cases, rapid testing with 10–20% potassium hydroxide and
microscopic examination can provide valuable clue to diagnosis. Since
early initiation of treatment is vital, this information can provide ground
for management.
TREATMENT
Mycetoma
Simple surgical excision is curative. Antifungal drugs are not indicated.
Allergic Fungal Rhinosinusitis
■ Surgery is routinely required in these cases to alleviate symptoms and
also reduce fungal and mucin load. Most cases can now be managed by
endoscopic surgery.
■ Follow-up protocols vary among institutes. Steroids are mainstay of
postoperative management. Topical and oral steroids may be used till
normal mucosa is obtained and followed up for many years.
■ Antifungals have debatable ecacy.
BA
Figs. 8.3A and B: Patient in Figure 8.2 after debridement and the defect (A) and after recon-
struction with anterolateral thigh free ap (B).
Invasive Fungal Sinusitis
■ Treatment depends on various factors. Chronic invasive sinusitis
patients, who are immune competent may be managed by debridement
and oral azole antifungals (Itraconazole and Voriconazole).
■ Acute invasive fungal sinusitis, however requires very aggressive and
early management. e immune compromised situation needs early
reversal and acidosis requires rapid control.
■ Mainstay of treatment is systemic amphotericin and surgical debridement. Amphotericin is toxic in causing renal and hematological adverse
eects and require close monitoring. Liposomal formulations of
amphotericin have enabled rapid build-up of antifungal concentrations
and are less toxic.
■ Debridement at times needs to be extensive and mandates removal of
necrotic bones and soft tissues of face, orbit, and nose. Defects can at
times be very debilitating and require reconstruction with aps when
patient is cured (Figs. 8.3A and B).
117Chapter 8 Fungal Diseases of Nose and Paranasal Sinuses: Surgical Aspects
REFERENCES
1. Ferguson BJ. Fungal rhinosinusitis: a spectrum of disease. In: Ramanathan Jr,
Mims JW. e Otolaryngologic Clinics of North America. Masson SAS; Elsevier;
2017. pp. 227-454.
2. Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology: Head and
Neck Surgery, 6th edition. Canada: Saunders-Elsevier; 2015.
9
CHAPTER
Pre- and Post-Functional
Endoscopic Sinus
Surgery Imaging
Ankur Goyal, Ashu Seith Bhalla, Arvind Kumar Kairo
• Terminology
• Functional Endoscopic
Sinus Surgery (FESS)
– Indications
– Basic Principles
– Steps of Surgery
• Pre-Functional Endoscopic Sinus
Surgery (Pre-FESS) Imaging
– Structured Reporting
▪ Mapping Sinus Involvement
▪ Detailing Drainage Pathways
▪ Anatomic Variants
• Post-Functional Endoscopic Sinus
Surgery (Post-FESS) Appearance
• Complications of FESS
– Immediate/Early Complications
▪ Cerebrospinal Fluid
Rhinorrhea
▪ Orbital Complications
▪ Vascular Complications
– Late Complications
▪ Recurrence
▪ Empty Nose Syndrome
▪ Rare Complications
▪ Lipogranuloma
TERMINOLOGY
■ Endoscopic sinus surgery (ESS): Generic term for all sinus surgeries
performed through the endoscopic route.
■ Besides diseases of the paranasal sinuses, endoscopic trans-sinus route
provides a way to surgically approach lesions of the orbit and anterior
skull base (ASB) [e.g. repair for cerebrospinal uid (CSF) leak].
■ Functional endoscopic sinus surgery (FESS)—is a type of endoscopic
sinus surgery which refers to minimally invasive treatment to restore
sinus ventilation and normal function. It is done only for non-neoplastic
mucosal diseases.
FUNCTIONAL ENDOSCOPIC SINUS SURGERY FESS
Goal of functional endoscopic sinus surgery is to reestablish the normal
mucociliary clearance and normal ventilation in cases of refractory
rhinosinusitis. Every sinus has its own natural pattern of drainage and innate
mucociliary clearance pattern. Obstruction in the paths of these pathways
inhibits proper clearance.
Indications
■ Refractory sinus obstruction, not responding to medical therapy
■ Polyps
■ Mucoceles.
Basic Principles
■ e procedure involves removing the diseased mucosa, preserving the
maximum normal mucosa and optimally widening the natural ostia of
the sinuses.
■ Osteomeatal complex (OMC) is the main area to be operated in FESS
since even minimal inammation can lead to obstruction of drainage
and ventilation of maxillary, anterior ethmoid and frontal sinuses.
■ If FESS is done from anterior to posterior direction, then it is called
Messerklinger technique and the reverse is known as Wigand technique.
■ 0 and 30 degree endoscopes (sinuscope) are must for FESS.
■ 45, 70, and 90 degree sinuscopes are also available to visualize hidden
areas.
Steps of Surgery
It is not necessary to open every sinus ostia; thus, surgery is tailor-made for
each case according to requirement/scenario. e common sequence of
steps is as follows:
1. Medialization of middle turbinate to open up middle meatal area.
2. Uncinectomy—removal of uncinate process. Incomplete removal of
uncinate is a common cause of failure of FESS as it plays key role in
OMC formation.
3. Middle meatal antrostomy: Identication and enlargement of the
natural opening of the maxillary sinus into the middle meatus.
4. Frontal sinusotomy and clearance of the frontal recess.
5. Anterior ethmoidectomy: Opening the ethmoid bulla.
6. Posterior ethmoidectomy and sphenoidotomy: Breaching the basal
lamina.
119Chapter 9 Pre- and Post-Functional Endoscopic Sinus Surgery Imaging
PREFUNCTIONAL ENDOSCOPIC SINUS
SURGERY PREFESS IMAGING
■ Multidetector computed tomography (MDCT) images should be viewed
on a workstation in all the three planes [(1) axial, (2) coronal, and (3)
sagittal] (Table 9.1).
■ Additional oblique planes may also be used as and when required.
Section 2 Inammatory Nasal Conditions120
Table 9.1: Utility of the dierent planes in
multidetector computed tomography (MDCT).
Plane Structures best delineated
Coronal • Osteomeatal complex (OMC)
• Frontal sinus drainage pathway
• Cribriform plate
• Lamina papyracea
• Nasal septum deviation and spurs
• Vertical attachment of the middle turbinate
Axial • Basal lamella (dividing anterior from posterior ethmoidal cells)
• Sphenoethmoidal recess
• Sphenoid ostium
Sagittal • OMC
• Frontal sinus drainage pathway (parasagittal images)
• Frontal recess
• Bulla ethmoidalis
• Uncinate process
• Ethmoidalaircellsdrainage:Anterior→middlemeatus
Posterior→sphenoethmoidalrecess
• Agger nasi cells
• Sphenoid ostia
Structured Reporting
■ It is important to use a structured reporting format for reporting CT scans
of paranasal sinus diseases (Table 9.2 and Figs. 9.1A to F).
■ e preprocedural radiology report should encompass following
components:
• Mapping sinus involvement
• Detailing drainage pathways
• Anatomic variants especially critical variants (for instance uncinated
process, olfactory fossa, Heller cell, and Onodi cell)
• Relevant details of surrounding structures (orbit, cranium, and oral
cavity)
• Incidental ndings, if any.
Mapping Sinus Involvement
■ is involves detailing the extent of disease and complications.
■ Listing of sinuses involved and assigning pattern.
■ Comment on attenuation of secretions—hyperdense secretions should
be specically mentioned.
■ Status of sinus walls—mucoperiosteal thickening/erosion
• Hyperostosis: Extensive drilling required and there is a need to rule out
alternative etiology
• Dehiscence: Risk of penetration.
■ Caution—exclude tumor as a cause for obstruction.
Detailing Drainage Pathways
■ Since the aim of FESS is to restore drainage pathways, detailing the
involvement of these is critical.
Anatomic Variants
■ ese may contribute to obstruction of drainage pathways and/or pose a
surgical risk. Hence the need of detailing them in radiology reports.
■ e structure wise anatomic variants are detailed in Chapter 2.
■ e anatomic variants can be classied into three categories:
1. ose obstructing the drainage pathways: refer Chapter 2.
2. ose posing a surgical risk and may require alterations in surgical
technique (Table 9.3 and Figs. 9.2A to F).
3. ose responsible for recurrent disease are enlisted in Table 9.4.
Table 9.2: Structured reporting format.
Admitting diagnosis: Nasal obstruction
Report
RT LT
1. Opacicationofsinuses(present/
absent)
Frontal sinus A A
Ethmoid sinus A A
Maxillary sinus A P
Sphenoid sinus A A
2. Mucoperiosteal thickening of sinuses
(present/absent)
Frontal sinus P P
Ethmoid sinus P P
Maxillary sinus P P
Sphenoid sinus P A
3. Any hyperdense contents
(mention site)
4. Pneumatization of sinuses
(normal/hypoplastic)
Frontal sinus N N
Ethmoid sinus N N
Maxillary sinus N N
Sphenoid sinus—sellar N N
Sphenoid sinus—presellar H H
No No
121Chapter 9 Pre- and Post-Functional Endoscopic Sinus Surgery Imaging
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