Ent Trends- Issue 1, July 2009

ISSUE 1 JULY 2009 VOLUME 1

ENT E– NEWSLETTER ON RECENT TRENDS IN ENT

Fungal sinusitis Issue 1

TRYST WITH HISTORY

ALLERGIC FUNGAL

RHINOSINUSITIS

FUNGAL SINUSITIS:

CURRENT TRENDS

RADIOLOGY OF

FUNGAL SINUSITIS

JOURNAL SCAN

QUIZ

� TRYST WITH HISTORY

� FUNGAL SINUSITIS: RECENT TRENDS

� QUIZ

© Dr. Pooja Kataria, New Delhi, July 2009

trends

ForewordForewordForewordForeword

Volume 1 Issue 1 July 2009 Pg2

Dear colleagues,

Being an academician for more than twenty years, I have witnessed

the ever changing scenario of teaching and acquiring knowledge. We

have come a long way from attending lectures, flocking the librar-

ies to now, virtually sitting at home and getting all the information

at click of a button. Shaking hands with the technological advance-

ment and to further our knowledge of Otorhinolaryngology, we have

decided to launch a newsletter. Each issue of this e- newsletter

will focus on a particular topic of clinical or academic importance

and will touch upon everything, from historical aspects to the re-

cent trends. The success of this endeavor will depend on your con-

tributions and feedback. This concept is originated by youngsters

and should be encouraged. I hope that this will receive all your

support and guidance. I wish the editors and authors the best of

luck and congratulate them for their effort.

DR. A. K. AGARWAL Dean and Director Professor ENT, Maulana Azad Medical College

ENT TODAY VOL. 1, ISSUE1. JULY 2009

E- NEWSLETTER ON RECENT

Modern practice of medicine offers vast information on every topic, but on the downside confuses us with multitude of treatment options. Experience coupled with our knowledge on a particular topic gathered from our institutions or otherwise, guides us through the proper management. Keeping abreast with the ongoing research and ever changing thera-peutic guidelines, we have taken upon us the task to compile a newsletter. Our attempt will be to outline the national and international treatment guidelines along with the recent trends on a particular disease, in each issue. Through this e-newsletter, our humble effort is to interact with as many ENT surgeons and expand our knowledge pool with their feedback.

We hope you enjoy reading this issue as much as we did compil-ing it. This issue focuses on the controversial topic of fungal sinusitis and its debatable management. We plan to take out the next issue on some interesting ear topic, may be the illustrious “cochlear implant”:) Since in medicine, there is one rule that there is no rule, inputs from varied sources will lead to enrichment of our skills, particu-larly of those graduates who are in the formative stages of their career. We solicit contributions from as many ENT practitioners, and sincerely hope that this e-newsletter will grow with each passing day.

Volume 1 Issue 1 July 2009 Pg3

E-Mail: [email protected]

Advisor

Dr. A.K. Agarwal

Editorial Board

Pooja Kataria Sumit Mrig Ankush Sayal

History has never fascinated us medicos, but of course we like to know how and when great minds

discovered the techniques and equipment we use today.

The most significant advances in medicine in this century have been the discovery of antibiotics, the

invention of various computerized scans and endoscopy of the various body cavities.

The first revolutionary change in the surgical treatment of the sinuses was the introduction and refine-

ment of endoscopic techniques. The second important development in the modern history of rhinol-

ogy was the introduction of powered instrumentation. Now we are seeing a third turning point, which

is the use of intraoperative image guidance in endoscopic sinus surgery.

Endoscopes are used in many branches of medicine today, so much so, there is no body cavity one

cannot have a look into. The endoscopes used for nasal sinus endoscopy are rigid tubes consisting of

rod lenses. The optical system used has been developed by Prof. H.H.Hopkins has larger viewing an-

gles and transmit brighter light.

Special instruments developed for the purpose are passed alongside the endoscope into the nose

and operations are carried out using key hole surgery principle. Though the idea was conceived and

early work was done by Prof. Messerklinger of Graz, Austria, it is Prof.H.Stammberger who popularized

Endoscopic sinus surgery in the English speaking world. The radical Endoscopic spheno-fronto-maxillo

-ethmoidectomy we do for massive polyps and fungal sinusitis would not fit into the original descrip-

tion of FESS by Dr. Kennely and Prof. Stammberger. Hence it is referred to as Endoscopic Sinus Surgery

(ESS).

The first powered instrument (microdebrider, or soft tissue shaver) was designed and patented by an

Otolaryngologist, Dr. J.C. Urban, in 1969, for use in microscopic ear surgery. Powered instruments be-

came very useful in orthopedic arthroscopic surgery in the 1970s and were used in Otolaryngology-

Head & Neck Surgery in the 1990s, after the introduction of endoscopic techniques made their use

more practical.

Reuben Setliff was the first physician to successfully demonstrate that powered cutting tools could be

used with precision control and safety in the nose and paranasal sinuses in humans. The first Micro-

Debrider was adapted from a tool produced for use in small joint arthroscopy in the wrist and TMJ.

Volume 1 Issue 1 July 2009 Pg 4

Tryst with HistoryTryst with HistoryTryst with HistoryTryst with History

Allergic fungal rhinosinusitis

History:

The combination of nasal polyposis, crust formation, and

sinus cultures yielding Aspergillus was first noted in 1976

by Safirstein who observed the clinical similarity that this

constellation of findings shared with allergic bronchopul-

monary Aspergillosis ( ABPA). In 1981, Millar et al

described five cases of chronic Aspergillus fumigatus

sinusitis in which the sinus exudates appeared histologically

similar to the inspissated bronchial mucus plugs in patients

with ABPA. The authors named the condition “allergic

aspergillosis of the paranasal sinuses”. In 1983, Katzenstein

and colleagues retrospectively reviewed 113 consecutive

surgical histopathologic specimens from chronic sinusitis

surgeries. Seven (6%) were identified as “allergic

aspergillus sinusitis”. Histologically the extramucosal

material was characterized as “allergic mucin”- degenerat-

ing eosiniphils, desquamated respiratory epithelial cells, and

Charcot-Leyden crystals. Fungal stains showed fungal

hyphae in the allergic mucin, but not in the mucosa. There

was no histologic evidence for tissue invasion by the fungi.

Many others also reported identical findings thereafter and

more cases have been described since then, not only with

Aspergillus spp. but with other fungi such as Bipolaris,

Alternaria, Curvilaria, and Exserohilum.

Allergic fungal sinusitis (or allergic fungal rhinosinusitis;

AFRS) is a term introduced by Robson et al in 1989.

Comparision to ABPA AFRS is believed to have an etiology similar to that of

ABPA. As more is understood about the pathophysiology of

ABPA than AFRS, the former is discussed as possible

model for the processes involved in AFRS.

These diseases are initiated by immunological reactivity to

antigens of Aspergillus species in the sinuses or bronchi of

affected individuals; and may be components of a wide

spectrum of compartmental allergic manifestations in the

respiratory tract.

Pathophysiology:

The exact pathophysiology of AFRS remains a matter of

conjecture for which several theories have been offered.

One popular theory proposed by Manning and col-

leagues is based on the assumption that AFRS exists as

nasal correlate of allergic bronchopulmonary aspergillo-

sis, of the disease.

It is depicted in a diagrammatic representation on the

next page. At some point this cycle becomes self-

perpetuating and results in the eventual product of this

process: allergic mucin; accumulation of which obstructs

the involved sinuses and propagates the process.

Certain unanswered questions regarding this theory • If AFRS is an IgE mediated disease, then why does it

predominantly occur in a unilateral fashion

• Why does fungal specific IgE remain elevated after

prolonged fungal immunotherapy when normally it

should decrease?

Hence, although it remains clear that the eosinophils play

an important role in the development of AFRS; eosino-

philic inflammation may occur as a final common path-

way in response to a number of different inflammatory

starting points.

Clinical presentation:

Patients typically present with

• gradual nasal airway obstruction and production of

semisolid nasal crusts that, on inquiry, match the

gross description of allergic fungal mucin.

• The development of nasal obstruction may have been

so gradual that the patient is unaware of its presence.

• Pain is uncommon among patients with AFRS and

suggests the concomitant presence of a bacterial

rhinosinusitis.

• Patients with AFRS are atopic but generally have

been unresponsive to antihistamines, intranasal corti-

costeroids, and prior therapy. The use of systemic

corticosteroids may produce some relief of symp-

toms, but relapse typically follows completion of

therapy.

Physical findings on examination, range from nasal

obstruction to gross facial disfigurement and orbital or

ocular abnormalities.


Initiation of inflammatory cascade leading to AFRS is a multifactorial event

-

-mucostasis -Fungal exposure -Atopy

-anatomic anomaly -T-lymphocyte

susceptibility

P.S: block arrows indicating points of intervention to break the cycle

Inflammation Eosinophilic inflammation

MBP, ECP, etc)

Fungal Proliferation

Antigenic exposure

Inflammatory trigger

Gel & Coombs TypeI & III

T– Cell

Others

Edema Obstruction

Stasis

Decreased ventilation

Allergic mucin

Anatomic factors

Immunotherapy Steroids

Bacterial

infection

Exposure Nasal saline irrigation

s u r g e r y


Local Environmental Genetic

Radiologic findings:

Soft tissue attenuation areas with internal hyperdensity are seen on non-contrast CT scans. These findings are although

not specific for AFRS, but they are relatively characteristic and provide preoperative information supportive of the

diagnosis of AFRS. The ethmoid sinus is the most commonly involved sinus, whereas the lamina papyracea is the most

common bone to exhibit demineralization. The presence of accumulations of heavy metals (iron, manganese) and

calcium salt precipitation within the inspissated allergic mucin is the most likely cause of these radiologic findings.

On MRI, presence of hypointense central T1 signal, central T2 signal void, and increased peripheral T1/T2 enhance-

ment is highly specific for AFRS as compared with other forms of fungal sinusitis. The high protein and low water

concentration of allergic fungal mucin, coupled with the high water content within surrounding edematous paranasal

sinus mucosa, gives rise to specific MR characteristics.

Laboratory findings:

Immunologic tests: Total IgE levels is a useful indicator of AFRS clinical activity. It is generally elevated to more than

1000 U/ml. Patients usually demonstrate positive skin test and in vitro ( RAST) responses for both fungal and nonfungal

antigens.

Histology of allergic fungal mucin: Allergic mucin is the hallmark of this disease. Grossly, it is thick, tenacious, and

highly viscous in consistency; its color may vary from light tan to brown or dark green. Histologic examination reveals

branching noninvasive fungal hyphae within sheets of eosinophils and Charcot-Leyden crystals.

Culture of fungi: Fungal cultures provide some supportive evidence helpful in diagnosis and subsequent treatment of

AFRS, but it is important to realize that the diagnosis of AFRS is not established or eliminated on the results of these

cultures. Various species of fungi have been cultured including Bipolaris, Curvalaria, Aspergillus, Exserohilum and

Alternaria.



Diagnosis:

Although certain signs and symptoms , as well as radiographic, intraoperative, and pathologic findings, may

cause the physician to suspect allergic fungal sinusitis, no standards had been defined for establishing the

diagnosis.

Parameters which enhanced the index of suspicion were as stated by Waxman et al (laryngoscope 1987):

(1)Young adults, (2)Recurrent polyposis, (3)History of asthma, (4)Multiple affected sinuses, (5)History of poor

response to medical management, (6)Multiple surgical procedures, (7)Thick inspissated intracavity mucus, (8)

Atopic patients with nasal polyps.

Many others used the combination of radiologic, laboratory and histologic parameters to distinguish AFRS from

other forms of rhinosinusitis.

In 1996, Bent and Kuhn laid down the diagnostic criteria, which are the most widely accepted.

These are as follows:

• Type I hypersensitivity confirmed by history, skin tests, or serology

• Nasal polyposis

• Characteristic CT signs- serpiginous areas of increased attenuation within the sinus cavity.

• Eosinophilic mucin without fungal invasion

• Positive fungal stain

• Asthma

• Unilateral predominance

• Radiographic bone erosion

• Positive fungal culture

• Charcot-Leyden crystals

• Peripheral eosinophilia

Of the criteria mentioned, allergic or eosinophilic mucin and atopy (Type I hypersensitivity) are considered

the most diagnostic of all.

Treatment:

Long term control of AFRS requires both elimination of fungal antigen by surgical therapy and control of its

recurrence by medical therapy. As early as 1979, it was established by McGuirt et al, that the treatment of

paranasal sinus aspergillosis is surgical and the key to which is the removal of diseased mucosa and aeration

and drainage of the involved sinus. Previously, procedures such as open antrostomies, intranasal sphenoeth-

moidectomies, lateral rhinotomies, and craniofacial resection were done. More radical procedures were also

being done because the clinical and radiographic evidence of invasion into adjacent spaces, were interpreted

as evidence of malignancy or invasive fungal disease. And hence, more morbidities and mortalities were en-

countered.

Changes have evolved in both medical and surgical arms of therapy. Radical surgery for AFRS has given

way to more conservative, tissue-sparing techniques, “conservative, but complete” as proposed by Mabry et

al.

M

A

J

O

R

M

I

N

O

R


Preoperative therapy: It is accepted that to decrease intranasal inflammation and nasal polyp volume,

systemic prednisolone (0.5 to 1.0 mg/kg/day) should be started 7 days before surgery. Preoperative antibiotics

should also be instituted because of the frequency of concomitant postobstructive bacterial sinusitis.

Goals of surgical treatment:

• Surgery should result in complete extirpation of all allergic mucin and fungal debris, reducing or eliminating the

antigen-inciting factor within the atopic individual. Polyps can provide an important intraoperative role by serving as a

marker of disease.

• Second goal of the surgery is to provide permanent drainage and ventilation of the affected sinuses while preserv-

ing the integrity of underlying mucosa.

• Final goal of the surgery is to provide postoperative access to the previously diseased areas, as even under ideal

conditions, some residual fungus may remain in situ inciting recurrence if not controlled postoperatively.

Medical therapy:

Corticosteroids: Topical corticosteroids are accepted as standard therapy in postoperative treatment of AFRS, but they

possess a limited benefit before surgery because nasal access is restricted. Kupferberg et al refined the endoscopic

follow-up into a staging system, which allows closer control of the mucosal response to medical management, that is,

oral steroids.

Oral prednisone (0.4 mg/kg per day)- 4 days

reduction by 0.1 mg/kg/day

in cycles of 4 days

Oral prednisone 20 mg/day, or 0.2 mg/kg/day (whichever is greater)- 1 month

Oral prednisone 0.2 mg/kg/day

monthly follow-ups with nasal endoscopy

and serum IgE levels

Dose adjusted based on maintenance of Stage 0- 4 months

Oral prednisone at 0.1 mg/kg/day plus intranasal steroid

spray at triple dose- one spray in each nostril 3 times daily

patient maintained at Stage 0 for 2 months

Oral prednisone tapered to zero, intranasal steroid spray continued for 1 year

Follow up till 5 years : endoscopy and serum IgE levels monthly for 6 months, bimonthly for 3-5 years.

STAGING SYSTEM BASED ON

ENDOSCOPIC FINDINGS

0

no mucosal edema or allergic

mucin

I

mucosal edema with or without

allergic mucin

II

polypoid edema with or without

allergic mucin

III

sinus polyps with fungal debris or

allergic mucin


Antifungals: In vitro studies of use of oral antifungals show promising results in AFRS, but in vivo studies

are pending. However, the expense, limited available data, and potential drug-related morbidity of systemic antifungal

therapy may limit the usefulness of this form of treatment for noninvasive fungal disease. Topical application of anti-

fungal agents may hold some benefit in the control of postoperative recurrence. A study by Fenna et al (Laryngoscope

February 2009), examined the effect of topical Amphotericin B on inflammatory markers in patients with chronic

rhinosinusitis, and concluded that it has no significant effect on activation markers of nasal inflammatory cells.

Immunotherapy: The similarity between AFRS and ABPA led to a theoretical concern that immunotherapy using spe-

cific fungal antigens in patients with either of these diseases might incite further allergic reactions by adding to the pa-

tient’s fungal antigenic stimulus and possible exacerbation of immune complex development and deposition. However,

in the case of AFRS, surgery theoretically allows removal of the inciting fungal load from the paranasal sinuses and

hence, immunotherapy after surgery may be beneficial rather than harmful.

Surgical exenteration of sinuses + confirmation of diagnosis

Allergy evaluation and testing( RAST and quantitative skin tests) for relevant fungal

and non-fungal antigens appropriate for the area.

Avoidance measures Treatment protocol explained to patient

Pharmacotherapy Informed consent

adjusted

One vial prepared of all positive non-fungal antigens

Second vial of all positive fungal antigens

(vial test with each performed)

Weekly immunotherapy placing one injection from each vial in a different arm

(for accurate recognition of cause of any local reactions)

dose advancement as tolerated,

patient observed for local reactions,

adverse changes in nasal signs/symptoms,

adjustment of medical management based on endoscopic examination for

re-accumulation of allergic mucin or reformation of polyps

Immunotherapy continued for about 3-5 years.

Follow-up

• Postoperatively for at least 3 years.

• Postoperative treatment with oral corticosteroids, topical steroid nasal sprays, antihistaminics and deconges-

tants (if indicated), anti-leukotrienes ( may be!?) and nasal sinus lavage are followed. Allergen immunother-

apy if available is started as detailed.

• Postoperative follow-up includes monitoring changes in clinical status and serial measurements of total

serum IgE which in-turn guide the dose changes of oral corticosteroids and addition of antibiotics, if needed.

Progressive decrease in total serum IgE levels is a good prognostic sign, that encourages prednisone taper-

ing according to protocol. A progressive rise in total serum IgE levels during follow-up, or a rise that occurs

repeatedly during attempted prednisone tapers should alert the clinician to probable recurrent surgical AFRS

and the need for additional surgical evaluation.

Goals to be achieved

• To keep clinical rhinosinusitis minimal and forestall the need for recurrent sinus surgery.

• To taper oral corticosteroids without significant worsening of condition.

• To minimize treatment related steroid side effects.


Author details:

Dr. Pooja Kataria, Specialist, ESI Hospital, Basaidarapur, New Delhi.


Fungal sinusitis: current trends

The following section will give you a brief overview of what’s latest in management of fungal sinusitis. The following section will give you a brief overview of what’s latest in management of fungal sinusitis. The following section will give you a brief overview of what’s latest in management of fungal sinusitis. The following section will give you a brief overview of what’s latest in management of fungal sinusitis. We will try to highlight newer, amazing discoveries and tickle your brains to explore the topics in We will try to highlight newer, amazing discoveries and tickle your brains to explore the topics in We will try to highlight newer, amazing discoveries and tickle your brains to explore the topics in We will try to highlight newer, amazing discoveries and tickle your brains to explore the topics in

detail :)detail :)detail :)detail :)

The classification which is currently being followed for fungal sinusitis is proposed by de

Shazo et al:

AND ONGOING RESEARCH

Syndrome Common

causes

Host character-

istics

Associated con-

ditions

Histopathologi-

cal findings

Clinical presen-

tation

Treatment Prognosis

Allergic fungal

rhinosinusitis

Bipolaris

Species, Curvu-

laria lunata &

Aspergillus

fumigatus

Immunocompe-

tent, frequently

atopic

Chronic

rhinosinusitis,

nasal polyps

Eosinophil-rich

mucoid material

(allergic mucin)

Chronic pansi-

nusitis nasal

polyps, prop-

tosis or eye–

muscle entrap-

ment in children

Debridement,

aeration, oral

and topical cor-

ticosteroids, ?

immunotherapy

Recurrence

common

Sinus fungal

ball

(mycetoma)

A. fumigatus

and A. flavus

Immunocompe-

tent

Chronic

rhinosinusitis Dense accumu-

lation of fungal

elements in a

mucoid matrix

Rhinosinusitis

( often U/L),

Nasal obstruc-

tion, green-

brown nasal

discharge

Debridement,

aeration, anti-

fungal agents

not required

Excellent

Acute invasive

fungal

rhinosinusitis

Mucorales and

Aspergillus

Immunocom-

promised, rarely

immunocompe-

tent

Diabetes melli-

tus, malignant

conditions,

Immunosuppres-

sive therapy

Fungal elements

in mucosa, sub-

mucosal, blood

vessels or bone,

extensive tissue

necrosis

Fever, cough,

crusting of nasal

mucosa, epis-

taxis, headache,

mental status

change

Radical debride-

ment until his-

tologically nor-

mal tissue is

evident, antifun-

gal agents,

treatment of

underlying con-

ditions

Fair when dis-

ease is limited

to sinus, poor

with intracranial

involvement

Chronic inva-

sive fungal

rhinosinusitis

A. fumigatus Immunocompe-

tent

Diabetes

mellitus

Necrosis of mu-

cosa, submuco-

sal, bone &

blood vessels,

low grade

inflammation

Orbital apex

syndrome,

nerve palsy

Radical debride-

ment, antifungal

agents

Variable, long-

term survey

required

Granulomatous

invasive fungal

rhinosinusitis

A. flavus Immunocompe-

tent

None Granulomas

with multinucle-

ate giant cells,

histiocytes

Unilateral prop-

tosis

Debridement,

aeration, and

antifungal

agents

Good, but dis-

ease can recur


Advances in treatment

The triazoles are newer, and are less toxic and more effective:

• Fluconazole

• Itraconazole

• Ravuconazole

• Posaconazole

• Voriconazole

Newer recommendations for treatment of invasive aspergillosis:

• Voriconazole as primary therapy in most patients

• Liposomal amphotericin—alternative therapy in some patients

• Options for salvage therapy; dependent on prior therapy, host factors, dosing considerations; potential

agents: posaconazole, itraconazole, echinocandins, lipid amphotericin formulations.

• Prophylaxis with posaconazole can be recommended in high risk patients (Walsh TJ, et al. Clin Infect Dis

2008;46:327-60)

Role of topical antifungals:

• The Mayo clinic has found that 6 months of irrigation with Amphotericin (250 micrograms/ml) showed 75 % im-

provement not only in the amount of mucosal thickening on the CT scan as well as endoscopic scores.

• The Mayo clinic is now recommending a concentration of 100 micrograms/ml.

• Although when given intravenously there are serious side effects with Amphotericin B, topically it causes minimal

problems.

• Some patients seem to respond to treatment with oral antifungals, including Sporanox, Diflucan, and possibly

Nizoral.

Intranasal application of amphotericin B. Patients apply 20 mL of antifungal solution into each nostril using a bulb syringe. Arrow shows hand movement to accomplish suc-cessful application of the antifungal drug from me-dial (ethmoid) to lateral


Advances in endoscopic sinus surgery

Otolaryngologists have employed computer-aided surgery, or image-guided surgery, over the past two decades to en-

hance surgeon’s confidence, allow more thorough surgical dissections and possibly reduce the complication rate of

endoscopic sinus surgery. Computer-aided surgery utilizes preoperative imaging to provide real-time localization of

surgical instruments in the surgical field. Although computer-aided surgery originated in the neurosurgical realm, oto-

laryngologists soon appreciated that this technology could assist in identifying critical orbital or intracranial structures

surrounding the paranasal sinuses, and potentially aid in decreasing complications. In this article, the history of image-

guidance systems and their application to surgery of the paranasal sinuses and skull base will be reviewed. The compo-

nents of computer-aided surgery systems and the currently available technologies for surgical instrument tracking are

discussed, as well as the advantages and disadvantages of each of the tracking technologies.

• The term "stereotactic" was coined from Greek and Latin roots meaning "touch in space”.

• A colorful term for this surgery is “neuro-navigation”.

• Use images of the paranasal sinusis and the brain to guide the surgeon to a target within the brain by utilizing the

stereotactic principle of co-registration of the patient with an imaging study.

Frameless stereotactic surgery

• Based on the principle of the global positioning system.

• Relies on anatomical landmarks on the patient’s head and/or fiducial markers (temporary skin markers) which are

taped to the scalp before the brain is imaged.

• In the operating room the orientation of these markers is used to register the computer containing the brain im-

ages.

• References this coordinate system with a parallel coordinate system of the three-dimensional image data of the

patient that is displayed on the console of a computer-workstation so that the medical images become point-to-

point maps of the corresponding actual locations.


IMAGE GUIDED SURGERY

Image-guided surgery (IGS), also known as surgical navigation, is a specific technology that visually correlates intraop-

erative anatomy with preoperative CT scans. Often IGS is considered to be analogous to the global position system

(GPS), a technology that permits individuals to show their relative position on computer-generated map. For IGS, the

preoperative CT scan serves as the map, and the intraoperative tracking system is similar to the satellites and devices

that are used for GPS.

During nasal surgery, an IGS system will show the position of an instrument tip relative to the preoperative CT scan

images. Thus, the surgeon is better able to correlate intraoperative anatomy with the preoperative CT scans.

Image-guided surgery may be helpful in situations

• where complications might otherwise occur because of difficulty with recognizing the usual anatomy.

• in case of frontal sinus disease,

• in patients who need to be re-operated.

The CT scan images represent the coronal and reconstructed sagittal and axial views. The probe is at the level of the

middle turbinate. As you can see, the cross-hairs indicate exactly where the probe is on each of the coronal, sagittal

and axial views.


The use of navigation for ENT procedures has improved patient outcomes. Its main uses are :

• Revision sinus surgery

• Distorted sinus anatomy of development, postoperative, or traumatic origin

• Extensive sino-nasal polyposis

• Pathology involving the frontal, posterior ethmoid and sphenoid sinuses.

• Disease abutting the skull base, orbit, optic nerve or carotid artery

• CSF rhinorrhea or conditions where there is a skull base defect

• Benign and malignant sino-nasal neoplasms.

The primary advantages to using our navigation solutions for FESS include:

• Procedures are much less invasive than open surgical operations.

• Precision is greater, resulting in lower risk to the patient.

• Patient discomfort is minimal.

• Procedure recovery time is shorter.

ENT Procedures that can be done using the navigation system:

• Transphenoidal procedures

• Maxillary antrostomies

• Ethmoidectomies

• Sphenoidotomies/ sphenoid explorations

• Turbinate resections

• Frontal sinusotomies

The ENT system is not only significantly more complex, it has to be more intuitive, as the cranial anatomy with all its

sinuses, and nerves, and arteries and veins, is much more intricate.

The system's navigation coordinates are provided by the Patient Registration Mask.


BALLOON SINOPLASTY

• Sinus guide catheter is introduced into the nasal cavity under endoscopic visualization, sinus guide wire is intro-

duced through the catheter and advanced into the target sinus.

• The sinus balloon catheter is introduced over the sinus guide wire and is positioned across the blocked ostium.

The position of the balloon catheter is confirmed, and the balloon is gradually inflated to remodel the nar-

rowed or blocked ostium.

• The balloon catheter is then deflated and removed, leaving the ostium open.

Author details:

Dr. Sumit Mrig, Senior Resident, Department of ENT & Head and Neck surgery, Maulana Azad Medical

College, Lok Nayak Hospital & Associated Hospitals.


a b

Non-contrast CT image (a) in a patient with

diabetic ketoacidosis with acute fungal sinusi-

tis shows hypoattenuationg soft tissue within

the nasal cavity & left ethmoid & frontal si-

nuses.

Intracranial extension is clearly evident in this

contrast enhanced T1W MRI image (b).

RADIOLOGYRADIOLOGYRADIOLOGYRADIOLOGY

In ENT practice, CT offers great help not only in diagnosis but also in planning of sinus surgery, where half the exercise is already per-

formed before actually starting the surgery by reconstructing 3D images of sinuses in the head of the operating surgeon.

The radiologic characteristics of fungal sinusitis are very specific and aid in diagnosis and also guide towards the mode and the tim-

ing of appropriate treatment. Understanding the different types of fungal sinusitis and knowing their particular radiologic features

allows the radiologist to play a crucial role in alerting the clinician to use appropriate diagnostic techniques for confirmation. Prompt

diagnosis and initiation of appropriate therapy are essential to avoid a protracted or fatal outcome.

Acute Invasive Fungal Sinusitis Acute invasive fungal sinusitis is seen predominantly in immuno-compromised patients or those with poorly controlled diabetes.

Along with sinuses, nasal cavity is a frequent site of infection, with middle turbinate accounting for two-thirds of positive biopsy

results. Angioinvasion and hematogenous dissemination are frequent with a mortality ranging from 50-80%.

Hypoattenuating mucosal thickening or soft-tissue attenuation within the lumen of the involved paranasal sinus and nasal cavity is

seen on NCCT. There is a predilection for unilateral involvement of the ethmoid and sphenoid sinuses. Rapid, aggressive bone de-

struction of the sinus walls is seen with intracranial and intraorbital extension of the inflammation. However, bone erosion may

even be absent or very subtle and fungi tend to extend beyond the sinuses, along the blood vessels. Other complications include

cavernous sinus thrombosis, carotid artery invasion, occlusion, or pseudoaneurysm with resulting cerebral infarct and hemorrhage.

Whereas CT is better to assess for bone changes, MR imaging is superior in evaluating intracranial and intraorbital extension of the

disease. Obliteration of the periantral fat is a subtle sign of extension beyond the maxillary sinus & should be specifically looked for.

Leptomeningeal enhancement may be seen with intracranial invasion and with progressive infection, adjacent cerebritis, granulo-

mas, and abscess formation may be seen. Intracranial granulomas appear hypointense on both T1- and T2-weighted images with

minimal enhancement on contrast enhanced images.

Chronic Invasive Fungal Sinusitis

It usually occurs in immunocompetent individuals; however those with diabetes or a low level of immunosupression are susceptible.

Patients usually have a history of chronic rhinosinusitis with a persistent & recurrent disease. Noncontrast CT reveals a hyperattenu-

ating soft-tissue collection within one or more paranasal sinuses. Mottled lucencies or irregular bone destruction may be seen in the

paranasal sinuses. There may also be sclerotic changes in the bony walls of the affected sinuses representing chronic sinus disease.


a

b

c

There is decreased signal intensity on T1-weighted MR images and markedly decreased signal intensity on T2-weighted images.

Infiltration of the periantral soft tissues about the maxillary sinus is an indicator of invasive disease. Invasion of adjacent structures

such as the orbit, cavernous sinus, and anterior cranial fossa may lead to epidural abscess, parenchymal cerebritis or abscess,

meningitis, cavernous sinus thrombosis, osteomyelitis, mycotic aneurysm, stroke, and hematogenous dissemination. Cranial nerve

palsies occur with perineural spread. It may be mass like and differentiation from a malignancy may not be possible on imaging

with destruction of the sinus walls and extension beyond the sinus.

Chronic invasive fungal sinusitis:

(a) Clinical photograph of the patient showing perforation of the hard palate.

(b) Coronal and T2W image showing left maxillary and ethmoid sinusitis . There is destruction of nasal turbinates, ethmoidal septae and

hard palate forming an oro-nasal fistula (arrow).

(c) Coronal post gadolinium showing a fungal granulomas with peripheral enhancing rim in left cavernous sinus & evidence of perineu

ral spread with thickened enhancing mandibular division of trigeminal nerve coursing through the widened foramen ovale (black arrow)

Chronic Granulomatous Invasive Fungal Sinusitis

This form primarily is primarily found in Africa & Southeast Asia. Individuals are generally immunocompetent & disease is charac-

terised by formation of noncaseating granulomas in the tissues. Cross-sectional imaging findings are reported to be similar to

those of chronic invasive fungal sinusitis. They may mimic an invasive mass lesion, with descriptive findings difficult to distinguish

from those of a malignant neoplasm invading the paranasal sinuses, orbital soft tissues, infratemporal fossa, and skull base.

Allergic Fungal Sinusitis

Allergic fungal sinusitis is the most common type of fungal sinusitis & underlying cause is thought to be a hypersensitivity reaction

to certain inhaled fungal organisms. It is characterised by the presence of “allergic mucin”, a yellow green inspissated mucus

which contains eosinophils & Charcot-Leyden crystals. Allergic fungal sinusitis usually occurs in younger individuals that are im-

munocompetent, and often have a history of atopy. Involvement of multiple sinuses is a rule. Disease tends to be bilateral with a

frequent nasal component. The majority of the sinuses show near-complete opacification and are expanded. Noncontrast CT dem-

onstrates hyperattenuating allergic mucin within the lumen of the paranasal sinus. T1W images may reveal high signal intensity or

mixed low, intermediate, and high signal intensity in these patients. There is characteristic low signal intensity or signal void on T2-

weighted images, which is attributed to a high concentration of various metals such as iron, magnesium, and manganese concen-

trated by the fungal organisms.


The T2 signal void is also attributed to a high protein and low free-water content of the allergic mucin. The inflamed mucosal lining

is relatively hypointense on T1-weighted images and hyperintense on T2-weighted images and demonstrates enhancement after

intravenous administration of gadolinium contrast material. There is no enhancement in the center or in majority of the sinus con-

tents, which distinguishes this condition from neoplastic entities. Although the condition is not considered invasive, if left un-

treated, the involved sinuses expand and there is smooth bone erosion with subsequent intracranial or intraorbital extension and

resulting cranial or orbital symptoms. Intracranial extension is usually limited by the dura to the extradural space.

Fungus Ball Fungus ball appears as a mass within the lumen of a paranasal sinus and is usually limited to one sinus. The maxillary sinus is the

most commonly involved sinus. A fungus ball typically appears hyperattenuating at noncontrast CT due to dense matted fungal

hyphae & may demonstrate punctuate calcifications. The bony walls of the sinus may be sclerotic and thickened or expanded and

thinned with focal areas of erosion from pressure necrosis. The fungus ball is hypointense on T1-weighted and T2-weighted im-

ages owing to the absence of free water. Calcifications and paramagnetic metals such as iron, magnesium, and manganese also

generate areas of signal void on T2-weighted images.

Author Details:

Dr. Vaibhav Jain, Consultant, Department of Radiology, Max Hospital

Pitampura, New Delhi.

a b

c d

Allergic fungal sinusitis:

Axial unenhanced CT scans (a,b) show expan-

sion of and increased attenuation in the ante-

rior ethmoid, posterior ethmoid, sphenoid, and

frontal sinuses bilaterally. There is characteristic

hyperattenuating material within these sinuses

(black arrows). Note also the smooth thinning of

the posterior wall of the left frontal sinus (white

arrows in b).

On MRI (same patient) unenhanced T1-

weighted images (c) show characteristic high

signal intensity within the left maxillary, left

posterior ethmoid, and sphenoid sinuses

(arrows in c). Corresponding T2-weighted MR

images (d) show marked low signal intensity

within the left maxillary, left posterior ethmoid,

and sphenoid sinuses (arrows in d).


JOURNAL SCANJOURNAL SCANJOURNAL SCANJOURNAL SCAN

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254-9.

Katzenstein AL, Sale SR, Greenberger PA. Allergic Aspergillus sinusitis: a newly recognized form of si-

nusitis. Journal of Allergy and Clinical Immunology. 1983; 72: 89-93.

Waxman JE, Spector JG, Sale SR, Katzenstein AL. Allergic Aspergillus sinusitis: concepts in diagnosis

and treatment of a new clinical entity. Laryngoscope. 1987; 97: 261-6.

Bent 3rd JP, Kuhn FA. Diagnosis of allergic fungal sinusitis. Otolaryngology and Head and Neck Sur-

gery. 1994; 111: 580-8.

Mabry RL. Allergic and infective rhinosinusitis:differential diagnosis and interrelationship. Otolaryngol-

ogy and Head and Neck Surgery. 1994; 111: 335-9.

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2001; 111: 1006-19.

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For answers, click on the link below:

http://enttrends.webs.com/

1. The best confirmation of the diagnosis of AFRS requires:

A. a positive fungal culture from the nose

B. A positive fungal culture from the sinus.

C. An elevated total serum IgE

D. Positive surgical sinus histopathology.

E. Positive fungal specific precipitins.

2. The following are true regarding the treatment and follow-up of patients with AFRS except:

A. directional trending of total serum IgE level can be prognostic

B. Current research indicates oral antifungal drugs are effective as adjunctive treatment

C. Amphotericin B is generally contraindicated

D. oral corticosteroids have been found to decrease both symptoms and time to surgical recurrence

E. Patients should be co-managed by both medical and surgical specialists.

3. Which of the following statements regarding fungal sinusitis is/are correct:

A. Bone destruction or extrasinus spread on imaging is essential for diagnosing invasive form.

B. CT scan is the first modality of choice in such patients.

C. Allergic type does not show bone destruction or intraorbital/intracranial spread.

D. Intraorbital & intracranial extension is best depicted on thin slice axial & coronal CT.

E. Loss of periantral fat pad is a sensitive marker for invasive variety.

4. Match the following radiological descriptions to the most probable type of fungal sinusitis:

A. Mixed low & hyperattenuating material in left maxillary sinus on CT with tiny calcific specks.

B. A diabetic with complaints of nasal obstruction & discharge for four months, with recent onset

proptosis showing hyperattenuating soft tissue opacification of left ethmoid & maxillary sinuses,

erosion & sclerosis of maxillary sinus walls & orbital cellulitis on CT.

C. Bilateral frontal, anterior ethmoid & posterior ethmoid sinus involvement with hyperintense mate-

rial on T1W and hypointense on T2W images, with mild expansion.

D. T2 hyperintense mucosal thickening in maxillary, ethmoid and sphenoid sinuses with lack of visuali-

zation of flow void of left intracavernosal ICA.

DISCLAIMER

The opinions published in this publication are those of the contributors and do not

necessarily reflect the opinion or recommendations of the publishers. The publisher

assumes no liability for any injury and or damage to persons and property as a matter of

products liability, negligence or otherwise, or from use of operation of any methods,

products instructions or ideas contained in the material herein. No warranties, either ex-

press or implied, are made with respect to its accuracy, completeness, or timeliness. Due

to rapid advance in medical science, an independent verification of the methodologies and

references quoted here is strongly recommended.

………………………………………………………………………………………………………………………Publisher

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