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• W2443171421 abstract "Brief ReportAspergillus Sinusitis: A Radiologic Study Fatma A. Al-Mulhim and MD Ezzat E. DawlatlyFRCS(Ed), FRCS (Lond) Fatma A. Al-Mulhim Search for more papers by this author and Ezzat E. Dawlatly Search for more papers by this author Published Online:1 Sep 1995https://doi.org/10.5144/0256-4947.1995.535SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionFungi of the genus Aspergillus are spore-producing filamentous organisms. The spores are ubiquitous in the environment, growing on dead leaves, stored grain, compost piles, hay and other decaying vegetation. While inhalation of Aspergillus spores is extremely common, Aspergillus disease of the nose and sinuses is rare. Under certain conditions, Aspergillus may become pathogenic to man. The lung is the most frequent site of infection but other sites may be involved, including the liver, spleen, bone, meninges and sinuses. In the majority of cases, the fungus acts as an opportunistic pathogen in immunosuppressed patients. Aspergillus sinusitis in nonimmunosuppressed patients presents in two distinct forms. In allergic Aspergillus sinusitis (AAS), a ball of hyphae forms in a chronically obstructed paranasal sinus in association with recurrent nasal polyposis and without tissue destruction. In the much less common primary paranasal Aspergillus granuloma (PPAG), a chronic fibrosing granulomatous process usually starts in one sinus and, untreated, tends to spread to the orbit and intracranially.1,2This paper compares and contrasts the radiological features in six patients suffering from Aspergillus sinus disease, seen during the last eight years. Three had AAS and three had PPAG.Material and MethodsBetween the years 1985 and 1993, radiological data on patients with a confirmed diagnosis of Aspergillus sinusitis were reviewed. The material studied consisted of plain films of the chest and paranasal sinuses and computed tomography (CT) scan of the head in all patients, cerebral angiograms in two patients and magnetic resonance (MR) imaging of the head in one patient (Table 1). A confirmed diagnosis was based on clinical history, operative findings and pathology data.Table 1 Radiological findings in patients with AAS and PPAG.DiagnosisCase 1 (AAS)Case 2 (AAS)Case 3 (AAS)Case 4 (PPAG)Case 5 (PPAG)Case 6 (PPAG)Age22306165453SexFFMFMMPlain film Soft tissue++++++ Metallic shadows+++−−− Bone expansion+++−−− Bone destruction−−−+++ Unilateral involvement−−++++ Bilateral involvement++−−−−CT Soft tissue++++++ Metallic shadows+++−−− Bone expansion+++−−− Bone destruction−−−+++ Intraorbital extension−+−++− Intracranial extension−−−+++ Contrast enhancement−−−not done++Cranial angiographynot donenot donenot donenot done−−ResultsOver an eight-year period, six patients with the diagnosis of Aspergillus sinusitis were identified. There were three males and three females. The median age was 31 years. All patients were healthy with normal immune status. None suffered from diabetes or asthma. Plain films of the chest were negative in all. Plain films and CT scan of the paranasal sinuses were obtained in all the patients. Angiograms were obtained in two patients and MR imaging was obtained in one patient.Three patients with AAS presented with recurrent nasal polyps.3 The plain films showed bilateral opacification of multiple sinuses with involvement of the nasal fossa similar to the findings in bilateral nasal polyposis with expansion of the sinuses and thinning of the bone. CT scan of the head accurately delineated the extent of the lesion in each patient. Extensive hyperdense soft tissue masses involving the nose and paranasal sinuses with characteristic hyperdense tissues were identified in all patients. These hyperdense tissues were not clearly demonstrated on plain films. There was expansion of the sinuses without evidence of bone destruction (Figure 1A). One patient with unilateral involvement treated by radical surgery (patient 3 in Table 1) returned three years later with extensive disease in the other side without recurrence in the original side (Figure 1B). Ethmoid expansion without infiltration of the orbits was observed in one patient (Figure 2, patient 2 in Table 1). The same patient presented 10 years later with recurrence of the lesions without bony destruction or intracranial extension. No contrast enhancement was noted in any patient after injection of contrast media. No intracranial extensions were seen in any patients.FIGURE 1B The same patient as figure 1A after three years demonstrates extensive involvement of the left side.Download FigureFIGURE 2 Thirty-year-old female with AAS: axial CT showing expansion of the soft tissue mass into the left orbit without infiltration of the orbital contents.Download FigureIn patients with PPAG, plain films showed unilateral opacification of one or more sinuses, indistinguishable from bacterial infection. Absence of air fluid level together with evidence of bone destruction, though nonspecific, are the most characteristic features of PPAG.4 CT scan of all three patients clearly demarcated the extent of the soft tissue mass lesion, which appeared more aggressive. There was evidence of bone destruction, orbital infiltration (Figure 3) and intracranial extension. The intracranial extension through bony defects was in sharp contrast to the relatively free nasal airway (Figure 4), which explains the lack of early nasal symptoms in PPAG. The masses were of isointense density in the precontrast study. They enhanced after injection of contrast, especially the intracranial portion (Figure 4).FIGURE 3 Sixteen-year-old female with PPAG: axial CT showing bilateral orbital infiltration.Download FigureFIGURE 4 Fifty-four-year-old male with PPAG: coronal CT of the sinuses after contrast injection showing enhanced soft tissue mass involving the right side with bony destruction and intracranial extension.Download FigureCerebral angiography performed on two patients with intracranial extension where malignant tumors were expected revealed lack of tumor circulation and only showed displacement of blood vessels, mainly due to mass effect. MR imaging of one patient with PPAG with intracranial extension showed the extent of the lesion and brain involvement with sharp delineation of the margins and determined the most common pattern, which was the ring-enhancing lesions consistent with abscesses. On T2-weighted MR images, the ring in these lesions was noted to be irregular and hypointense.5 Bone involvement was not adequately evaluated due to MR limitation in assessment of fine bone.DiscussionFungal infection of the paranasal sinuses is an uncommon disease. In healthy, nonimmunocompromised nondiabetic patients, Aspergillus sinusitis is the most common fungal disease. Aspergillus infection of the sinuses can be localized and presumably saprophytic as in AAS or invasive with serious complications in PPAG.6Radiology plays an important role in the early diagnosis, management and follow-up. A high index of suspicion may help avoid the serious complications associated with PPAG. Plain films of chronic sinusitis which appear unilateral with expansion and/or bone destruction in otherwise healthy patients should raise the suspicion of fungal infections. CT scan provides better soft tissue discrimination with good visualization of bone and it provides valuable information about the character and integrity of adjacent bone and intracranial complications.7 MR imaging with its superior soft tissue contrast resolution, multiplanar imaging capabilities and lack of ionizing radiation helps in showing the extent of the intracranial extension and the pattern of involvement.Patients with allergic Aspergillus sinusitis present with nasal obstruction and recurrent nasal polyps. Plain films show clouding or opacification of multiple sinuses; the maxillary sinuses are most commonly involved.8CT scanning demonstrates clearly the extent of involvement of multiple sinuses with lobulated soft tissue masses which contain areas of hyperdense calcifications resembling metallic foreign bodies. This radiological pattern is due to dense concretions of calcium phosphate in the sinus fungal masses and it is regarded as pathognomonic of aspergillosis in the absence of a history of foreign body.6 There is expansion of the sinuses and distortion of the normal anatomy without bone destruction. Expansion into the orbit was seen in one patient.9On the other hand, patients with PPAG are often asymptomatic and usually present with unilateral exophthalmos4,10 or symptoms related to the central nervous system. The disease usually starts in one sinus and relentlessly spreads to adjacent structures. These include other sinuses, the orbit, the cheek and, most devastatingly, the brain.Plain films show unilateral involvement with bone erosions and destruction. The clinical presentations are suggestive of neoplasms. CT scan with its superior soft tissue and bony evaluation clearly shows the bony destruction with the extent of the intraorbital and the intracranial involvement and helps to differentiate it from mucosa of the ethmoid or frontal sinus.This study clearly demonstrated the differences in the radiological features between allergic Aspergillus sinusitis and primary paranasal Aspergillus granuloma. The radiologist should be able to diagnose and alert the clinician to the probable diagnosis.Radiological investigation plays an important role in the diagnosis of Aspergillus sinusitis. It helps differentiate between allergic Aspergillus sinusitis, which is usually bilateral, associated with recurrent intranasal polyposis, and has a favorable outcome; and primary paranasal Aspergillus granuloma, which is usually unilateral, associated with minimal nasal symptoms, and could lead to fatal intracranial complications if not detected and treated early.11 CT scan provides the most accurate information in suggesting the diagnosis and in planning surgery.ARTICLE REFERENCES:1. Bennett JE. Fungal infections . In: Wilson JD, Braunwald E, Isselbacher KJ, et al.Harrison’s Principles of Internal Medicine, 12th ed.New York: McGraw-Hill; 1991;763-4. Google Scholar2. Meikle D, Yarington T, Winterbauer RH. Aspergillosis of the maxillary sinuses in otherwise healthy patients . Laryngoscope. 1985; 95:776-9. Google Scholar3. Katzenstein AA, Sale SR, Greenberger PA. Allergic aspergillus sinusitis: a newly recognized form of sinusitis . J Allergy Clin Immunol. 1983; 72:89-93. Google Scholar4. Rudwan MA, Sheik HA. Aspergilloma of paranasal sinuses - a common cause of unilateral proptosis in Sudan . Clin Radiol. 1976; 27:497-502. Google Scholar5. Ashdown BC, Tien RD, Felsberg GJ. Aspergillosis of the brain and paranasal sinuses in immunocompromised patients. CT and MR imaging findings . AJR. 1994; 162:155-9. Google Scholar6. Stammberger H, Jakes R, Beaufort F. Aspergillosis of the paranasal sinuses: x-ray diagnosis, histology and clinical aspects . Ann Otol, Rhinol, Laryngol. 1984; 93:251-6. Google Scholar7. Unger JM, Shaffer K, Duncavage JA. Computed tomography in nasal and paranasal sinus disease . Laryngoscope. 1984; 94:1319-24. Google Scholar8. Romett JL, Newman RK, Lackland AFB. Aspergillosis of the nose and paranasal sinuses . Laryngoscope. 1982; 92:764-6. Google Scholar9. Daghistani KJ, Jamal TS, Zaher S, Nassif OI. Allergic aspergillus sinusitis with proptosis . J Laryngol Otol. 1992; 106:799-803. Google Scholar10. El-Hassan AM. Primary paranasal aspergillus granuloma . Postgraduate Doctor-Middle East. 1985; 9:258-62. Google Scholar11. Savetsky L, Waltner J. Aspergillosis of the maxillary antrum. Report of a case and review of the available literature . Arch Otolaryngol. 1961; 74:695-8. Google ScholarFigures and TableFIGURE 1A Six-year old with AAS: coronal CT of the sinuses showing hyperdense expansive soft tissue mass on the right side, no bony destruction.Download Figure Previous article Next article FiguresReferencesRelatedDetails Volume 15, Issue 5September-October 1995 Metrics History Accepted1 April 1995Published online1 September 1995 AcknowledgmentOur sincere thanks to Mr. Abdel Moniem El-Tayeb of the Medical Photography Department of King Fahad Hospital of the University for the preparation of the prints.InformationCopyright © 1995, Annals of Saudi MedicineThis work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.PDF download" @default.
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