Case of the Month

ACUTE INVASIVE FUNGAL SINUSITIS

B Y: H A M E D B A S S E R I , P G Y- 2
C L I N I C A L P R E S E N TAT I O N :

An 80 yo male patient is brought to the ER with altered

level of consciousness with limited available history.

On Examination: the patient is febrile at 39.8oC. Right-

sided proptosis with periorbital swelling and erythema
is noted

A CT Head is ordered by the medical team

UNENHANCED CT HEAD FINDINGS:

Representative axial non-contrast CT Head images at the level

of base of skull.
UNENHANCED CT HEAD FINDINGS:

Representative axial non-contrast CT Head image in bone

window
UNENHANCED CT HEAD FINDINGS:

Representative coronal images from non-contrast CT Head.

The right images is presented in bone window.
IMAGING FINDINGS

CT demonstrates a lobulated heterogenous soft tissue

mass centred in the right pterygopalatine fossa

This mass involves the posterior nasal passage,

ethmoid and sphenoid sinuses

There is extensive bony destruction and evidence of

minimal intracranial extension

In addition, there is orbital extension of mass with

resultant proptosis
D I F F E R E N T I A L C O N S I D E R AT I O N S :

Acute Invasive Fungal Sinusitis

Sinonasal squamous cell carcinoma

Complicated Rhinosinusitis

Sinonasal Wegners Granulomatosis

Sinonasal Non-Hodgkin Lymphoma

DIAGNOSIS

While CT features were suggestive, they were not

sufficient to make the diagnosis

Endoscopic biopsy was performed

Pathology demonstrated high levels of fungal

elements (Mucor sp.) favouring diagnosis of acute
invasive fungal sinusitis

No pathologic features to suggest of neoplasm

A C U T E I N VA S I V E F U N G A L S I N U S I T I S
T Y P I C A L I M A G I N G F E AT U R E S
Non-contrast CT:

Soft tissue opacification with bony erosive changes

Often unilateral with involvement of sphenoid and ethmoid sinuses [1]

Can extend along vessels or intracranially with resultant complications

such as cavernous sinus thrombosis, carotid artery invasion/occlusion or
pseduoaneurysm [1]

Contrast -enhanced study is optimal for evaluation of soft tissue

infiltration as well as bony erosions [4]

MR

Better for assessment extent of intraocular extension [1]

Leptomeningeal enhancement should be excluded in early intracranial

extension [1]
A C U T E I N VA S I V E F U N G A L S I N U S I T I S
C L I N I C A L C O N S I D E R AT I O N S

Most commonly occurs in immunocompromised

patients, especially diabetics and elderly [5]

Mucormycosis and Aspergillus are the most common

causative organisms [5]

Variable clinical presentation: acute fever, facial pain,

nasal congestion, epistaxis, visual changes, altered
LOC [2]
 A C U T E I N VA S I V E F U N G A L S I N U S I T I S
MANAGEMENT

Acute invasive fungal sinusitis is a source of significant morbidity and

mortality [3]

Histopathologic diagnosis is crucial to guide management

Overall survival is poor with high risk of long term complications [2]

Treatment includes empiric IV antifungal therapy (ie. Amphotericin B) [2]

Surgical consultation for radical debridement is often necessary [2]

REFERENCES

[1] Aribandi M, McCoy VA, Bazan C 3rd. Imaging Features of Invasive

and Noninvasive Fungal Sinusitis: A Review. Radiographics. 2007
Sep-Oct;27(5):1283-96.
[2] Cox, GM & Perfect, JR (2016) Fungal rhinosinusitis. In: UpToDate.
UpToDate, Waltham, MA.
[3] Knipe H & Gaillard F. Acute Invasive Fungal Sinusitis. In:
Radiopedia.org. rID: 9367
[4] Michel, MA. (2016). Invasive Fungal Sinusitis. In: StatDx.
[5] OBrien, William T. Sr. (2010). Top 3 Differentials in Radiology.
New York, NY: Thieme Medical Publishers Inc.