Endoscopic Endonasal Surgery for Sinus Fungus Balls: Clinical, Radiological, Histopathological, and Microbiological Analysis of 40 Cases and Review of the Literature

Document Type : Original

Authors

1 Department of Otorhinolaryngology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy.

2 FPO IRCCS, Head & Neck Oncology Unit, Candiolo Cancer Institute, Turin, Italy.

3 Department of Diagnostic Imaging, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy.

4 Department of Otorhinolaryngology, University of Insubria, Varese, Italy.

Abstract

Introduction:
Paranasal sinus fungus ball (PSFB) is a non-invasive mycosis, which appears in immunocompetent patients, along with unilateral lesion. The purpose of this study was to analyse various symptoms of PSFB and its radiological, pathological, and microbiological findings. In addition, this study involved the investigation of the incidence of bacterial coinfection and surgical techniques applied for this infection and to report the modern developments in this domain.
Materials and Methods:
This retrospective study was carried out on 40 consecutive patients referring for PSFB treatment to the Ear, Nose, and Throat Department in San Luigi Gonzaga University Hospital, Turin, Italy, from April 2014 to 2017. Pertinent literature was reviewed and compared within the specified period. All patients were examined by preoperative computed tomography (CT) scan, and 26 (65%) patients were subjected to magnetic resonance imaging (MRI).
Results:
Totally,33 patients (82.5%) were affected with single sinus infection, whereas most of the cases suffered from maxillary sinusitis. With regard to CT scan findings, microcalcifications were found in 32.5% of the cases; however, mucosal membrane thickening around the fungus ball (FB) was visible in contrast-enhanced CT scans. According to MRI examination, FB showed a characteristic “signal void” on T 2(42.3%). Only 7(17.5%) patients had a positive mycological culture, whereas bacterial coinfections were identified in 47.5% of the cases. Out of 40 patients, 3(7.5%) subjects had only radiological evidence of fungal colonization while having no histopathological evidence. No patient received postoperative antifungal drugs, and there were no serious complications with only one recurrence.
Conclusion:
 Endoscopic endonasal surgery is the treatment of choice for patients with PSFB receiving no associated local or systemic antifungal therapy. A histopathological study facilitates the confirmation of the diagnosis and exclusion of the invasive form of fungal rhinosinusitis.
 

Keywords

Main Subjects

References

1. Stammberger H. Endoscopic surgery for mycotic and chronic recurring sinusitis. Ann Otol Rhinol Laryngol Suppl 1985;119:1-11.
2. Ferreiro JA, Carlson BA, Cody DT. Paranasal sinus fungus balls. Head Neck 1997; 19:481-6.
3. Karthikeyan P, Nirmal Coumare V. Incidence and presentation of fungal sinusitis in patient diagnosed with chronic rhinosinusitis. Indian J Otolaryngol Head Neck Surg 2010; 62(4):381-5.
4. Grosjean P, Weber R. Fungus ball of the paranasal sinus: a review. Eur Arch Otorhinolaryngol 2007; 264:461-70.
5. Pagella F, De Bernardi F, Dalla Gasperina D, Pusateri A, Matti E, Avato I et al. Invasive fungal rhinosinusitis in adult patients: our experience in diagnosis and management. J Craniomaxillofac Surg 2016; 44(4):512-20.
6. Pagella F, Matti E, De Bernardi F, Semino L, Cavanna C, Marone P et al. Paranasal sinus fungus ball: diagnosis and management. Mycoses 2007; 50(6): 451-6.
7. DeShazo RD, O’Brien M, Chapin K, Soto-Aguilar M, Gardner L, Swain R. A new classification and diagnostic criteria for invasive fungal sinusitis. Arch Otolaryngol Head Neck Surg 1997; 123:1181-8.
8. DeShazo RD, Chapin K, Swain RE. Fungal sinusitis. N Engl J Med 1997;337:254-9.
9. Castelnuovo P, De Bernardi F, Cavanna C, Pagella F, Bossolesi P, Marone P et al. Invasive fungal sinusitis due to Bipolaris hawaiiensis. Mycoses 2004;47:76-81.
10. Ferguson BJ. Fungus balls of the paranasal sinuses. Otolaryngol Clin North Am 2000;33:389-98.
11. Dufour X, Kauffmann-Lacroix C, Ferrie JC, Goujon JM; Rodier MH, Karkas A et al. Paranasal sinus fungus ball and surgery: a review of 175 cases. Rhinology 2005;43:34-9.
12. Pagella F, Pusateri A, Matti E, Giourgos G, Cavanna C, De Bernardi F et al. Sphenoid sinus fungus ball: our experience. Am J Rhinol Allergy 2011; 25:276-80.
13. Braun H, Buzina W, Freudenschuss K, Beham A, Stammberger H. Eosinophilic fungal rhinosinusitis: a common disorder in Europe? Laryngoscope 2003;113:264-9.
14. Najafzadeh MJ, Samani KJ, Houbraken J, Alizadeh M, Fata A, Naseri A et al. Identification of fungal causative agents of rhinosinusitis from Mashhad, Iran. Curr Med Mycol 2017;3(3):5-9.
15. Zanganeh E, Zarrinfar H, Rezaeetalab F, Fata A, Tohidi M, Najafzadeh MJ et al. Predominance of non-fumigatus Aspergillus species among patients suspected to pulmonary aspergillosis in a tropical and subtropical region of the Middle East. Microb Pathog 2018;116:296-300.
16. Kim JS, So SS, Kwon SH. The increasing incidence of paranasal sinus fungus ball: a retrospective cohort study in two hundred forty-five patients for fifteen years. Clin Otolaryngol 2017;42(1):175-9.
17. Klossek JM, Serrano E, Peloquin L, Percodani J, Fontanel JP, Pessey JJ. Functional endoscopic sinus surgery and 109 mycetomas of paranasal sinuses. Laryngoscope 1997;107:112-7.
18. Kim JS, Kim BK, Hong SD, Kim HJ, Kim KY. Clinical characteristics of sphenoid sinus fungal ball patients with visual disturbance. Clin Exp Otorhinolaryngol 2016;9(4):326-31.
19. Lop-Gros J, Gras-Cabrerizo JR, Bothe-González, Montserrat-Gili JR, Sumarroca-Trouboul A, Massegur-Solench H. Fungus ball of the paranasal sinuses: Analysis of our series of patients. Acta Otorrinolaringol Esp 2016;67(4):220-5.
20. Ilica AT, Mossa-Basha M, Maluf F, Izbudak I, Aygun N. Clinical and radiological features of fungal diseases of the paranasal sinuses. J Comput Assist Tomogr 2012;36(5):570-6.
21. Ledderose GJ, Braun T, Betz CS, Stelter K, Leunig A. Function endoscopic surgery of the paranasal fungus ball: clinical outcome, patient benefit and health related quality of life. Eur Arch Otorhinolaryngol 2012; 269:2203-8.
22. Wang JH, Lee BJ, Jang YJ. Bacterial coinfection and antimicrobial resistance in patients with paranasal sinus fungus balls. Ann Otol Rhinol Laryngol 2010;119:406-11.
23. DeShazo RD, O’Brien M, Chapin K, Soto-Aguilar M, Swain R, Lyons M et al. Criteria for the diagnosis of sinus mycetoma. J Allergy Clin Immunol 1997;99:475-85.
24. Chakrabarti A, Denning DW, Ferguson BJ, Ponikau J, Buzina W, et al. Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Laryngoscope 2009;119(9): 1809-18.
25. Lee KC. Clinical features of the paranasal sinus fungus ball. J Otolaryngol 2007;36: 270-73.
26. Nicolai P, Lombardi D, Tomenzoli D, Villaret AB, Piccioni M, Mensi M et al. Fungus ball of the paranasal sinuses: experience in 160 patients treated with endoscopic surgery. Laryngoscope 2009;119: 2275-79.
27. Zinreich SJ, Kennedy DW, Malat J, Curtin HD, Epstein JI, Huff LC et al. Fungal sinusitis: diagnosis with CT and MR imaging. Radiology 1988;169: 439-44.
28. Seo YJ, Kim J, Kim K, Lee JG, Kim CH, Yoon JH. Radiologic characteristics of sinonasal fungus ball: an analysis of 119 cases. Acta Radiol 2011; 52: 790-5.
29. Aït-Mansour A, Pezzettigotta S, Genty E, Faulcon P, Lecanu JB. Evaluation of the prevalence and specificities of asymptomatic paranasal sinus aspergillosis: retrospective study of 59 cases. Eur Ann Otorhinolaryngol Head Neck Dis 2015; 132(1):19-23.
30. Chuskaul S. Is high blood sugar a risk factor for paranasal sinus fungus ball? Otolaryngol Head Neck Surg 2013;149:261.
31. Chobillon MA, Jankowski R. What are the advantages of the endoscopic canine fossa approach in treating maxillary sinus aspergillomas? Rhinology 2004; 43:230-5.
32. Stammberger H, Jakse R, Beaufort F.  spergillosis of the paranasal sinuses: x-ray diagnosis, histopathology, and clinical aspects. Ann Otol Rhinol Laryngol 1984;93: 251-6.
33. Nomura K, Asaka D, Nakamaya T, Okushi T, Matsuwaki Y, Yoshimura T et al. Sinus fungus ball in the Japanese population: clinical imaging and characteristics for 104 cases. Int J Otolaryngol 2013; 2013:731640.
34. Tsai TL, Lan MY, Ho CY. There is no relationship between nasal septal deviation, concha bullosa, and paranasal sinus fungus balls. Sci World J  2012; 2012:181246.
35. Fadda GL, Rosso S, Aversa S, Petrelli A, Ondolo C, Succo G. Multiparametric statistical correlations between paranasal sinus anatomic variations and chronic rhinosinusitis. Acta Otorhinolaryngol Ital 2012;32(4):244-51.
36. Tomazic PV, Dostal E, Magyar M, Lang-Loidolt D, Wolf A, Koele W et al. Potential correlations of dentogenic factors to the development of clinically verified fungus balls: A retrospective computed tomography-based analysis. Laryngoscope 2016; 126(1): 39-43.
37. Dufour X, Kauffmann-Lacroix C, Ferrie JC, Goujon JM, Rodier MH, Klossek JM. Paranasal sinus fungus ball: epidemiology, clinical features and diagnosis. A retrospective analysis of 173 cases from a single medical center in France, 1989-2002. Med Mycol 2006;44(1):61-7.
38. Fadda GL, Berrone M, Crosetti E, Succo G. Monolateral sinonasal complications of dental disease or treatment: when does endoscopic endonasal surgery require an intraoral approach? Acta Otorhinolaryngol Ital 2016;36:300-9.
39. Mensi M, Piccioni M, Marsili F, Nicolai P, Sapelli PL, Latronico L. Risk of maxillary fungus ball in patients with endodontic treatment on maxillary teeth: a case-control study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103(3): 433-6.
40. Aribandi M, McCoy VA, Bazan C 3rd. Imaging features of invasive and noninvasive fungal sinusitis: a review. Radiographics 2007;27:1283-96.
41. Reddy CE, Gupta AK, Singh P. Imaging of granulomatous and chronic invasive fungal sinusitis: comparison with allergic fungal sinusitis. Otolaryngol Head Neck Surg 2010;143:294-300.
42. Panda NK, Balaji P, Chakrabarti A, Sharma SC, Reddy CE. Paranasal sinus aspergillosis: its categorization to develop a treatment protocol. Mycoses 2004;47:277–83.
Iranian Journal of Otorhinolaryngology
Volume 31, Issue 1
January and February 2019
Pages 35-44

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