Allergic Fungal Sinusitis - CT Findings

7/30/2019 Allergic Fungal Sinusitis - CT Findings

1/6

S uresh K . M ukhe rji, M DR am on E . F ig ue roa , M DLaw ren ce E . G insb e rg , M DB arb a ra A . Z eife r, M DB rad ley F . M arp le , M DJohn G . A lley , M DLaura 1 . C oope r , MDW illiam R . N em zek , M DD av id M . Yousem , M DK im R . Jon es , M DS teph en B . K up fe rbe rg , M DM au rido C astillo , M D

In dex te rm s:A n aphy lax is and alle rgy , 23 .205 ,

23 .63A s pe rg il lo si s, 2 3. 20 5P aranasa l sinuses, CT , 23 .1 2111Sinus it is , 23 .2 05 , 2 3 .25 , 23 .63Radio logy 1998 ; 207:41 7-422

1 F rom the D epartm en ts o f R ad io lo gy(5KM ., J.G .A ., M .C .), S urg ery (S .K .M .),Pa tho lo gy (L .L .C .) , and O to la ryngo l-og y (K .R .J .), U n iv ersity o f N orth C aro -lin a S choo l o f M edic in e, 33 24 O ldIn f irm ary CB 751 0 , Ch ape l H il l, N C27599-7 51 0 ; the D ep artm en ts o f R ad i-o logy(R .EF)andOto la ryngo logy(S .B .K .) ,M ed ica l C o llege o f G eorg ia , A ugus ta;the D epartm en t o f R ad io logy , M .D .A nderson C an cer C en ter , H ouston ,Tex (LEG .); th e D epartm en t o f R ad io l-og y , N ew Y ork Eye and E ar In firm ary ,B e th Is rae l M edica l C en te r, N ew York(B.A.Z.) ; the D ep ar tm en t o f O torh ino -laryng olo gy , U n ive rsi ty o fle xas Sou th-westem M edical C en ter , D allas (B .F .M .);the D epartm en t o f R ad io logy , U niver-si ty of C alifo rn ia a t D av is , S acram en to(W .R .N . ) ; and the D epartm en t o f R ad i-o logy , H osp ita l o f the U nivers ity o fPennsy lvan ia , P hilade lph ia (D .M .Y .). R e-ceived S ep 19 , 1997 ; rev ision requestedOct 2 2 ; final re v is ion re ceiv ed D ec 31 ;accep ted Ja n 1 5, 19 98 . A dd re ss re prin treques ts to S .K .M .

A uth or c on tr ib uti on s:G uaran to r o f in teg rity o f en tire s tudy ,S.K .M. ; s tudy co ncep ts and d esign ,S .K .M .; d e f in it ion o f in te llec tua l co n-ten t, S .K .M .; lite ra tu re resea rch , S .K .M .;c lin ic al s tu dies , S .K .M ., R .E .F ., L E.G .,B.A .Z . , B .F .M ., J.G .A ., LL .C ., W .R .N .,D .M .Y . , K .R .J ., S .B .K ., M C.; d a ta acqu i-s ition and ana lys is, S .K .M .; s tatis tica lana lys is, S .K .M .; m anuscr ip t p repara -tion and rev iew , S .K .M ., R .E .F ., LE .G .,B.A .Z . , B .F .M ., J .G .A ., LL .C ., W .R .N .,D .M .Y . , K .R .J ., S .B .K ., M .C .

41 7

A llerg ic F unga l S inu sitis :C T F ind in gs1

PURPOSE : T o dete rm ine the com puted tom og raph ic (C T ) find ings in pa tien ts w ithallergic fu ng al s in us itis .MATER IALS AND M EThODS : The au tho rs re tro spec tive ly re v iew ed CT scans andsu rg ica l and h is topa tho log ic repo rts in 45 pa tien ts (27 m a le , 1 8 fem a le ; age range ,8-68 yea rs ) w ith a lle rg ic funga l s inus itis from m u ltip le in s titu tions . T he m ed ian age(2 5 yea rs ) and dem og raph ics o f the pa tien ts w e re de te rm ined. Two head and neckrad io log is ts toge the r eva lua ted the C T scans fo r the p resence o f in tra s inus h igh -a ttenua tion areas , ex ten t o f s inus invo lvem en t, bone expans ion and th inn ing , bonee ros ion , and ex tens ion o f d isease in to the ad jacen t so ft tis sues .RESULTS : A lle rg ic funga l s inus itis w as m o re comm on in m a le pa tien ts and inpa tien ts aged 20 -30 yea rs . A ll pa tien ts had increased in tra s inus a ttenua tion a tnon -con tra s t m a te ria l-enhanced C T . M u ltip le s inus in vo lvem en t occu rred in 43pa tien ts . B ila te ra l in vo lvem en t was m o re comm on than un ila te ra l d is ease . F o rty -fou rpa tien ts had com p le te opac ifica tion o f a t leas t one o f the in vo lved s inuses ; 43 o fthese pa tien ts had expans ion of an in vo lved s inus , 42 had rem ode ling and th inn ingo f the bony s inus wa lls , and 41 had e ros ion o f the s inus w a ll.CONCLUS ION : A lle rg ic funga l s inus itis is a d is tin c t c lin ica l en tity w ith nonspec ifics ym p tom s that m ay be in itia lly sugges ted by the C T find ings . T hese find ings shou lda le rt the c lin ic ian to the poss ib ility o f a lle rg ic funga l s inus itis and p rom p t o the rd ia gn os tic s tu die s to e sta blish th e d ia gn os is a nd tre atm en t p la n.

A lle rg ic funga l sinus itis is a c lin ica l en tity now though t to be th e m o st comm on form offunga l s in usitis (1 ,2 ). D esp ite th is , a lle rg ic fu nga l sin usitis is the leas t unders to od fo rm offunga l sinus itis and m ay be und erd iagnosed b ecause it rem ains unfam ilia r to o to la ryng o lo -gists , pa tho log is ts, and rad io log ists (3 ). A ccurate d iagnos is is im portan t b ecause thetrea tm en t o f a lle rg ic funga l sin usitis is subs tan tia lly d iffe ren t from tha t o f o ther types offunga l s inus itis (1 ,4 ).

In the m ost recen t c lassifica tion sys tem (1 ), fu nga l sinus itis is d iv id ed in to inv asive andnon invas ive fo rm s . P atien ts w ith invas ive funga l s inus itis typ ica lly have acu te o nse t o ffever, co ugh , nasa l m u co sa l u lce ra tio n or escham s, ep istax is , and headache . A ffec tedin d iv idua ls are usu a lly imm unocom p rom ised . A ssoc ia ted cond itions inc lude d iab etesm ellitu s, severe m alnu tr ition , and m align ancy tha t resu lts in severe neu tm open ia .

T he m o st recen t c lassifica tio n sch em e lists the fo llow ing ca tegories o f invas iv e fun ga lsinusitis.

A cu te (fu lm inan t) fung al s inus itis is ch arac te rized h is to lo g ically b y in vasion of them uco sa , subm ucosa , o r b lo od vesse ls b y fun ga l hy phae . T he m ost comm on org an ism s areof the order M ucom ales and the genus and species A sp erg illu s fiu nig atu s. P atien ts w ith acu tefungal sinu sitis requ ire rad ica l d #{233}bn id em en t, an tifun ga l th erap y , an d trea tm en t o f theu nderly ing cond ition (1 ).

G ranu bom atous invas ive fun ga l s in usitis ( indo len t fu nga l s in usitis ) is a ra re cond itiontha t has been reported p rim ar ily in A frica and Sou theas t A sia , w ith sca tte red repo rts in th eU nited S ta tes. T h e d isease is charac te rized b y pro fuse fun gab grow th in the p aran asabsin uses and reg iona l tis sue inv as ion . A f ii m ig at us is the m os t comm only iso la ted o rgan ism .A ffec ted ind iv idu als appear to be imm unocom peten t, un lik e ind iv idua ls w ith acu teinvas iv e fung al s inus itis. H isto log ic exam ina tion rev eals n oncasea ting granu lom as w ithg ian t ce lls and p lasm a cells. T rea tm en t cons is ts o f su rg ical d #{233}bn idem ent and the adm in istra -tion of itracon azo le (1 ).


2/6

W e re tro spec tive ly rev iew ed CT scans andsu rg ica l and h is topa tho bog ic rep orts in 4 5

41 8 #{149}ad io logy #{149} a y1998 M ukhe rji .t a l

Chron ic inv as ive fung al s in usitis ischarac ter ized by a m o re p ro lo nged course .The d isease is typ ica lly assoc ia ted w itho rb ita l apex synd rom e ow ing to in tr ao r-b itab ex ten sion of d isease from the e th -m oid sin us. The m o st com m on ly iso la tedorgan ism is A sp erg illu s fla vu s. T hese p a -tien ts are u sually im munocom prom isedand requ ire trea tm en t s im ila r to tha t o fp a tien ts w ith acu te in vasive sinus itis (1 ) .Pat ien ts w it h n on in va si ve funga l sinusitispresen t w ith chron ic s inus itis that has fa iledto respon d to p rio r medica l o r su rg ica l treat-men t . The fo rm s of no n inv asiv e fu nga l s i-nusitis ar e ca teg orized as the fo llow in g .

M yce tom a is ch aracte r ized h istob og i-cabb y by a d en se accum u latio n o f f unga le lemen ts in a m uco id m atrix . A f um ig at usand the dem atiaceou s fung i a re the m o stcomm only iso la ted o rgan ism s. M yce tom asm ost frequ en tly a r ise in the maxif iary s inusand m ay o ccu r in assoda t ion with a c hr on i-ca lly d is ea sed sinu s o r po lyps (1 ) .

Al le rg ic fun gab s inus itis is a d isease ofy oung adu lts tha t has a geog raph ic p red i-lec tion fo r w arm and hum id clim ate s.The d isease is cha rac te r iz ed by the p re s-en ce o f a lle rg ic m ucin w ith in the in -vo lved sinu s. A t endo scopy , alle rg ic m u-on is a b row n or green ish -b lack m ate ria lth at h as the cons isten cy of co ttag e cheese .H isto log ica lly , it is com po sed o f lam i-na ted accum ulation s of in tac t and degen-e ratin g eosin oph ils , C ha rco t-L ey den c ry s-tabs, ce llu lar d eb ris, an d hyphae (1 ).

The d iagno stic c rite r ia fo r a lle rg ic fun -g a l s inusitis have recen tly b een u pda ted :(a ) the presence of a lle rg ic m ucin a t endos-co p y ; (b ) th e iden tif ic atio n o f fun ga l hy -p h ae w ith in a lle rg ic m ucin ; (c ) the ab-sence o f fun ga l invasio n of subm ucosa ,b lood vesse ls , o r bo ne ; (d ) the ab sen ce ofd iabe te s m ellitu s , im m unode ficiency d is-ease , o r recen t trea tm en t w ith imm unode-f iciency d ru gs; and (e ) rad io log ic con fir-m ation (1 ). In th e p as t, the im ag in gfind ings of a lle rg ic fun ga l sinu sitis weregrou ped toge the r w ith tho se o f o the rf o rms of fu nga l sinus itis (5 ). F ind ings o fseveral sm all se ries h ave sug gested tha timag ing stud ies m ay he lp to iden tify pa-t ients w ith a lle rg ic funga l s in usitis andshou ld be a part o f the d iagnos tic c rite ria(2,3,6-8). Th e purpose of ou r study w as torev iew th e com puted tom ographic(C F) find-in gs in p atie nts w ith su rg ica lly p roved a iler-gi c funga l s in usitis in an a ttem pt to de ter -mine charac te ris tic s sug gestive o f th e en tity .

MATER IAL S AND M ETHODS

pat ien ts (27 m ale , 18 fem ale ; m ed ian ag e,25 years ; m ean age , 2 7 .8 y ears ; ag e range ,8 -68 years at in itia l C T eva lu ation ) w itha lle rg ic fu nga l sin usitis . D iagn osis o f aller-g ic fu nga l sinu sitis in our se rie s w as basedon cr ite ria estab lish ed by D eShazo e t a l(1 ). A ll pa tien ts had cha rac ter is tic alle rg icm ucin a t end oscop y an d fun ga l hyph aeiden tified a t ligh t m ic rosco py . A lle rg icmuc in is a b rown or green ish -b lack m ate -n ab tha t has th e con sistency o f co ttagecheese . I t is com po sed o f lam in a ted accu -m ula tions o f in tac t and degenerat ing eo -s inoph ibs , Charco t-L eyden crysta ls , andce l lu la r d ebris (1 ) . F in d in g a lle rg ic m uc ina t end oscop y is th ough t to b e the sineq ua non fo r th e d iagnos is of a llerg ic fu ng alsinusitis (2 ,9 ) .

The presence of an alle rg ic h is to ry ofa top yand a G e ll an d Co omb s typ e I alle rg ichypersens i t iv i ty has been assoc ia ted witha lle rg ic fungab sinu sitis (4 ). H ow ever, anin -dep th a lle rg ic h isto ry w as no t ava il-ab le in our se ries because the m a jo rity o fpa tien ts d id n o t un de rg o com prehensiv ea llerg ic te sting be fo re su rg ery . T h is w asre la ted to the fac t tha t th e m a jo rity o fpa tien ts w ere trea ted by o to la ryng obo-g is ts w ho d id no t co nside r th e d iag nos isb efo re trea tm en t. T he pre sence o f a lle rg icm ucin a t en doscop y w as thou gh t to b esu ff icien t ev idence fo r in itiatin g trea t-m ent a fte r su rgery .

T he CT stu d ies w ere correla ted w ithsu rg ica l and h is to pa th obog ic repor ts in allpa tien ts. B ecau se ou r study w as a re tro -spec tive , m ulti- in stitu tio na l rev iew , th eim ag in g techn iques varied . A ll p atien tshad corona l n on-con tra st m a ter ia l-en -hanced CT stud ies recons truc ted w ithbone an d so ft-tissue alg o rithm s. A x ia lv iew s w ere rev iew ed w hen ava ilab le . Th esectio n th ickn ess w as 3 -5 mm .

The CT find ings in 35 of the p atien tsw ere rev iew ed toge the r by tw o head an dneck rad io lo g ists . T he CT find in gs in therema in ing 10 p atien ts w ere no t ava ilab lefo r rev iew becau se o f issues invo lv ingpa tien t ca re b u t w ere rev iew ed by expe ri-enced rad io log is ts (L .E .G ., W .R .N ., D .M .Y .)a t the ins titu tion a t w hich th ey w ereob ta ined . S tud ies w ere eva lu ated fo r(a ) the p re sence o f in tra sinu s h ig h -attenu -atio n a reas, (b ) the ex ten t o f s inus in vo lv e-men t , (c ) bone exp ansion and th in n ing ,(d ) bone erosion , an d (e ) ex tension ofd isease in to th e ad jacen t so f t tissues. B e-cau se o f the d ifficu lty in sep ara ting m d i-v idua l e thm oid s inuses on co rona l im ages,no a ttem pt wa s m ade to de te rm ine thespec ific ethm oid com partm en t in vo lv ed b yd isease . Thu s, the an te r io r , m idd le, an d po s-ten o r e thm o id s inuses w ere grouped to -ge the r as the e thm oid sinu s com plex .

CT F ind ings o f A lle rg ic Funga lSinusit isNo . o f

CT Find in g P a tien tsM ucosa l th icken in g 4 5 /45 (100 )

U nila te ra l 22 /4 5 (49)Bi la t e ra l 23 /45 (5 1)

I ncreased in tras inusa ttenu atio n 4 5 /45 (1 00)Invo lved sinusE thm o id 4 3 /45 (9 6)M ax illary 4 2 /45 (9 3)

F ron tal 32 /45 (71 )S ph eno id 30 /45 (67)

M ultip le sinus inv o lvem en t 43 /4 5 (96)C om ple te opac ifica tion of

a t le as t o ne sinu s 44/45 (98 )E xp an sio n o f o pa cif ie d

s in us 43 /44 (98 )Rem od eling of w alls o f

op ac ified sinu s 42 /44 (9 5)Th inn ing o f s inu s w all o f

opac ifie d sin us 4 1 /4 4 (93 )In vo lv em en t o f a dja ce ntsoft - t issue s truc tures 9 /45 (20)

N ote .-N um ber in paren theses is the percen t-ag e .

RESULTSC lin ical F ind ing s

. C lin ica l find ings in our ser ies sh ow edtha t alle rg ic fu nga l sinu sitis w as m o recomm on in m a le pa tien ts .

O ur re su lts are co nsis ten t with prio rreports tha t have su ggested a geog raph icd istribu tion o f a lle rg ic funga l sinusi t is(2 ,10 ,1 1 ). T h is ser ie s cons is ted o f casesob ta ined from seven academ ic ins titu -tions : fo u r in the sou th easte rn an d sou th -w estern and th ree in the northeaste rnand w este rn United S ta tes . Th e num berof p a tien ts from th e sou thern in stitu tio nsin w arm and hum id c lim ates (n = 3 1 ) w asgrea te r than the num ber from in stitu -t ions in d ry e r clim ate s (n = 14).

T he p re sen ting d in ica l com pla in ts w eren onspec if ic and con sisted m ain ly o f sym p -tom s of ch ron ic s in usitis. S ix pat ien ts withadvanced d ise ase a lso presen ted w ith prop to -si s in ad d ition to ch ron ic s in usitis ow ing toex tens ion ofal lerg ic ftm ga l s in us itis in to theretro bu lbar reg ion . N o pa tien ts had m en in -gitis or n eu .ro lo g ic sym ptom s due to in trac ra-n ial ex tens ion o f d isease.C T Find ing s

A ll of ou r pa tien ts had in creased in tra-s inus attenua tion w ith in the m ucosa lopac if ica tiononunenhanced stud ies (T ab le ).The m ucosal th icken ing in a lle rg ic fu ngabs inus itis invo lved any of th e sinuses. T h ee thm oid sinu s com plex w as m ost com -m only invo lved , w ith a t leas t one e th -


3/6

a. b.Figure 1 . A llerg ic fun gal s inu sitis w ith u n ila teral in vo lvem ent in a 25 -ye ar-o ld m an . (a ) Co ron alun enh an ced C T scan sh ow s the typ ical ap pea ran ce of u n ila teral a lle rg ic fu nga l sin usi tis . T he re isan exp an sile les ion cen te red in the rig h t m ax illa ry s inus an trum (A ) tha t a lso in vo lves theip sila tera l e thm o id sinu s com p lex (e ) and na sal cav ity )c ). T he in cre ased in tras inu s atte nu atio nsu gge sts that th is m a ss is a ben ig n inf lam m a tory proce ss ra the r than a m align an t s ino nasalneoplasm . (b ) B one -alg ori thm im ag e o f a dem onstra tes exp an sion and th inn ing o f the lam inapapyracea (ar row head ), the roo f o f the m ax illary sinu s (sm all cu rved arrow s), and the m ed ia l w a llo f the m axillary sin us (la rge curved a rrow ). C om pare th is w ith the no rm a l app earanc e o f the b onystructures on the le ft (sm all s tra igh t a rrow = co ntrala tera l lam ina p apy rac ea, la rge stra igh t a rrow s =m edial w a ll o f le ft m axillary s inu s).

Vo lum e 207 #{149}um ber 2 CT o f A lle rg ic F un ga l S inu s it is #{149}19

F igure 2 . A lle rg ic fun ga l sin usi tis w ith b ila tera linvo lvem en t in a 39-y ear-o ld m an . C oro na l unen-h anced CT scan show s op ac ifica tion of the m ax il-la ry and e thm o id sinuses. Ero sio n of the larn in ap apyracea (a rrowh ead) , p lan um sph en o ida le(w hite a rrow ), and orb ita l floo r (b lack ar row)cou ld a lso be seen in a slow ly grow in g neo pla sm .H ow ever, the d iffuse in tras in us a reas o f inc reasedattenu atio n su gge st a lle rg ic fun ga l s inu sitis .

m oid sinus com plex inv o lved in 43 (96% )of 4 5 pa tien ts. T h is w as fo llow ed in fre-q uency of invo lv em en t by the m ax illa rys inus (4 2 pa tien ts [93% ]), the fron ta l s i-nu s (32 pa tien ts [71% ]), and th e sp he-no id s inus (30 pa tien ts [67% j). M u ltip les inus invo lvem en t w as th e m ule : O n ly tw oo f th e 45 pa tien ts had d isease lim ited to

one sinus (o ne w ith d isease in the e th -m o id sinu s com p lex , one w ith d isease inthe m ax illa ry s in us).

Twen ty - two (4 9% ) of 45 pa tien ts hadu n ila te ra l in vo lvem en t, w ith th e righ t side(n = 15) invo lv ed m ore comm only th an theleft ( ii = 7) (F ig 1). Tw en ty - th ree (51% ) o f 45pa tien ts h ad b ila te ra l d isease (F ig s 2 , 3 ). O fthese 23 pa tien ts, 10 had symm etr ic invo lve-m en t an d 13 h ad asymm etric invo lvem en t.O f the 13 pa tien ts w ith asymm etric invo lv e-m en t, e igh t h ad d isease p redom inan tly onthe lef t s ide an d five had d isease pm edom i-nan tly o n the righ t.

For ty - four (98% ) of 45 pa tien ts had co rn -p le te opac if ica tion o f a t leas t o ne s in us. O fthese 44 pa tien ts, 4 3 (98% ) h ad expan siono f the opac ified s in us, 42 (95% ) h ad m em od-c lin g of th e bo ny s inu s w alls, and 4 1 (9 3% )dem onstra ted ero sion of a s in us w all.

N ine (2 0% ) o f the 45 pa tien ts hadev id en ce of d isease ex tend in g in to ad ja -cen t s truc tu res. A ll n ine pa tien ts hadbone em o sion : T hree had in tracm an ia l d is -ease ex tension , th ree had in trao rb ita l d is -ease ex ten sion , and th ree h ad bo th in tm a-orb ita l and in trac ran ia l d isease ex tens ion .O f these n ine p atien ts, s ix had b ila te ra ld isease and th ree had un ila teral d isease .

DISCUSSION

In th e span of o n ly 2 decad es, in te rest ina lle rg ic fun ga l s inus itis has g row n. T h is

d iagno sis sh ou ld b e su spec ted in a top icpa tien ts w ith ch ron ic , o ften in tractab lesinus itis and po ly pos is (1 ). T he sim ilam i-tie s a llerg ic fun ga l sinu sitis sh ares w itha lle rg ic b ronchopu lm onary aspem gillosisled to the firs t case repo rt by S af irs te in(12). M illam et a l (13) and la ter K atzen -ste in e t a l (1 4) no ted charac te ristic m u-co id sinus im pac tions and nasa l p o lypo-sis in sm all g rou ps of pa tien ts w ith chron icsinus itis . H isto log ic eva lua tion o f th a tm uco id m ate ria l revea led acu te b ran ch-ing fun ga l hyp hae tho ugh t to be a spec iesof the genus A sperg i l lu s . Term s such asa lle rg ic asperg illo sis o f the pam anasa l s i-n uses and a lle rg ic asperg illu s sinu sitisw ere in itia lly used to desc ribe the d isease .L a te r stud ies tha t re lied on ac tua l cu ltu reso f fu ng i rev ea led th e ro le o f dem atiaceousfung i in the pa thogenes is o f th is d isease ,p rom pting Robson et a l (15) to co in thete rm a llerg ic fu nga l s inus itis in 19 89 .T he m ost comm on fung i a re C urvu lar ia ,B ip o laris , P se iida !le sch eria , A sperg illu s, an dFiisari iun.

A lle rg ic funga l s inus itis con tinues to b eu ndem diagno sed b ecause it is o ften no trecog n ized as a d istinc t c lin ica l en tity(3 ,7 ) . In the past, a lle rg ic funga l sinu sitishas b een grouped under the broad c lassi-f ica tion of fung al s inus itis rath er thanrecog n ized as a sep arate d isease (5 , 1 6 , 1 7 ).R ecen t advances have led to a be tte run derstand in g of fung a l sinu s in fections(1 ). S evera l d iffe ren t en titie s a re n owth ough t to com po se w hat w as onceknow n co llec tiv ely as fu nga l sinu sitis(5 ). Fu nga l s inus d isease is now class if iedas (a ) a lle rg ic funga l s inus itis , (b ) s inusmyc e t oma , (c ) acu te (fu lm in an t) invas iv esinusitis, (d ) chron ic invas iv e fun ga l sinus-itis, and (e ) gm anu lom atou s in vasive fun-ga l s in usitis (1 ).

A lle rg ic fun ga l s inus itis m ay cons ti-tu te , in part, w ha t rad io lo g ists have m e-fem red to in the p as t as sup er im posedfu nga l co lon iza tion of the sinu ses. O urinv es tig a tion dem ons tra tes tha t the CTfind in gs tha t m ay sugges t a d iag nos is o fa lle rg ic fun ga l sinu sitis cons ist o f com -plete un ila te ra l o r b ila te ra l opac if ica tionof m ultip le pam anasa l s inuses , sinu s expan-s ion and eros io n of a w all o f th e invo lveds inus , and sca tte red in tm as inus h igh-a ttenua tio n areas am id m ucosa l th icken-in g on un enh anced C T scans.

O ur CT find ings a re s im ila r to tho seprev iou sly desc ribed b y M anning e t a l(2 ). B ecau se ou r s tud y is a re tro sp ec tiv eon e in w hich w e eva lua ted know n caseso f a lle rg ic fung a l s inus itis, w e canno tcon clud e tha t the im ag ing find ings a reh igh ly sp ecif ic , as p rev iou sly sug ge sted(2 ). H ow ever, ou r find ings sugg est tha t


4/6

42 0 #{149}ad io logy #{149} a y 19 98 M ukh er ji e t a l

the presen ce of a un ila te ra lly op ac ifieds inus assoc ia ted w ith sinu s expans ion ,bo ne rem od eling , an d in creased in te r-na l a ttenua tio n on unenhanced CT scan sshou ld ra ise the p oss ib ility o f alle rg icfu nga l s in usitis.

Bilatera l sinu s invo lvem en t a lso is com -m on and presen t in pa tien ts w ith ad-van ced d isease . Pa tien ts w ith advancedb ila te ra l invo lv em en t a re m ore lik ely tohave in trac ran ia l o r in trao rb ital ex ten -s ion of d isease a t the in itia l im ag ingeva lua tion th an are pa tien ts w ith un ila t-e ra l d isease (F ig 3). T he degree of b oneeros ion and ex tens ion beyond a sinusm ay m im ic aggressive s in onasa l neo -p lasm s. T he presence of inc reased in ter -nab a ttenua tio n on unenhanced CT scan sm ay h elp to d istingu ish alle rg ic fu nga ls inus itis from the m o re comm on s in ona-sal tum or (F ig 3) (5 ,17). It is co nce iv ab letha t ra re sino nasa l m en ing iom as o r sa rco -m as tha t p roduce a chond ro id or o steo idm atrix cou ld con ta in h igh-a tten ua tio nareas and m ay m im ic a lle rg ic fun ga l sinus-itis on unenh anced CT scan s. It a lso ispossib le tha t C T m ay no t be ab le to he lpd is tin gu ish alle rg ic fu nga l s in usitis fromdes icca ted secretion s w ith in m ucoce leso r p o lyps . H ow ever, the presence of cx -pans ion and th inn ing of the s inus w allsm ay he lp sep ara te alle rg ic funga l sinus itisfrom chron ic d isease w ith desicca ted se -c re tio ns, w hich often resu lts in th icken-ing and sc le ros is o f the ad jacen t s inusw alls (F ig 4).

O ur resu lts sugges t tha t CT m ay h elpiden tify p atien ts w ith a lle rg ic fun ga l s i-nus itis and m ay d iffe ren tia te th is fromother fo rm s of funga l sinus itis . T he CTfind ing of m yce tom a is a fo ca l ro und areaof inc reased a tten ua tio n tha t is u sua llycen te red w ith in a d iseased m ax illa ry s i-nus (1 ,16 ,17). C onversely , a lle rg ic fung alsinusit is typ ica lly in vo lves m ultip le s i-nuses , ex pands th e invo lv ed sinu s, and isassoc ia ted w ith d if fuse sca tte red in tras i-nus a reas o f inc reased a ttenua tio n . A cu tein vasive fu nga l s inus itis is charac ter izedby agg ress iv e bone eros io n w ith ex ten -sion of d isease in to th e ad jacen t so fttis su es (16 -18). In fection arising in them ax illa ry sinus m ay spread an te rio r ly in toth e can in e fossa o r pos te rio r ly in to thep te rygop ala tine fo ssa (1 9). It is uncom -m on for acu te in vasive fung al s in usitis toexpand a sinu s o r rem ode l a s in us w all.In trasinus h igh-a tten ua tio n areas a t CTare unu sua l in acu te invas ive fun gab sinus-itis (1 7 ,1 8). T h e im ag ing find ing s ofg ranu lom ato us and chro n ic inv as ive fu n-ga l s in usitis have no t b een c lea rly d e-fined . T hus , it is unc lear w he ther C T canbe used to d iffe ren tia te a lle rg ic fung al

s in usitis from these la tte r tw o d iseaseentities.

O ur find ing s re in fo rce the need to looka t so ft-tissue-a lgorithm im ages w hen per-fo rm in g C T in pa tien ts w ith chro n ic sin us-itis , b ec au se th e in tern al in tras inu s areasof inc reased attenua tion are best iden ti-fied at these se ttings . T he h igh attenua-tion in a lle rg ic fun ga l s in usitis is like lydu e to a com bina tio n of h eav y m eta ls(iron and m anganese) , ca lcium , and in -sp issa ted secre tion s tha t a re o ften fou ndin fun ga l e lem en ts (5 ,16 ,17 ,20 ).

O ur study is a re trospec tiv e ana lys is inw h ich w e eva lua ted the C T fin d ings ofdo cum ented cases o f a llerg ic funga l s inus-itis . B ecause w e d id no t com pare theim ag in g of a lle rg ic fun ga l s inus itis w iththa t o f s in onasa l po ly pos is o r w ith tha t o fm ucoce les , w e are unab le to comm en t o nthe pred ic tive va lue of o ur find in gs(2 ,3 ,4 ,11 ,21 ,22). Thus, ev en though ab le r-g ic fu nga l s in usitis m ay be sugg es ted , itmay no t be po ssib le to d if fere n tia te a ller -g ic fu nga l sinu sitis from advanced sin ona-sa l po lyp osis o r m ucoce les tha t a lso con-tam m ultip le m ycetom as or desicca tedsecre tio ns (F ig s 2 , 4 ) . It is p robab le th atear ly cases o f a lle rg ic fu nga l sinus itis w ithon ly partial o pac ifica tion o f the sinusesmay b e ind istin gu ish ab le f rom cases ofo ther no nfung al types o f m ucosa l th ick -en in g seen in pa tien ts p resen tin g w iths im ilar no nsp ecific sym ptom s.

Comm on spread pa tte rn s in ad vancedalle rg ic funga l sinu sitis inc luded in trao r-bita l ex tens ion th rough th e lam ina papy-m acca and in trac ran ial ex tens io n by m eansof e rosion of the spheno id s inus, p lanumspheno id ale , and pos te rio r w all o f thefron ta l s in us (F igs 1 , 3 ). T he bon e ex pan-s ion and th inn ing ty p ica lly assoc iatedw ith alle rg ic fun ga l sinus itis is like ly dueto p ressu re from a com bina tion of theu nderly ing sino nasa l po lypos is and thealle rg ic m ucin (2 ,6 ,22).

M agne tic reso nance (M R ) im ag ing doesn o t ap pear to p lay a su bstan tia l ro le inthe in itia l d iagnos is o f a lle rg ic funga ls inu sitis . Th e s ign al in te nsity loss in sin uscon ten ts reported in a lle rg ic funga l sinus-itis is lik ely du e to a com bina tion of anabsence of free ly m obile p ro tons and thep resence of heavy m eta ls w ith in densefu nga l con cretions . Th e concom itan t sus -cep tib ility e ffec ts tha t low er sign al in ten -s ity on T2-w eig h ted M R im ages are n o tspec ific to a lle rg ic fung al s inus itis andcou ld resu lt in the u nderestim atio n of theex ten t o f sinu s invo lv em en t a t M R im ag-ing (16 ,17) (F ig 5).

A s add itiona l in fo rm atio n has accum u-la ted , it has becom e increas in g ly ap par-en t tha t a lle rg ic funga l sinus itis rep re -

F igu re 3 . A dvanced a lle rg ic fun ga l s in usitism im ick in g an agg res sive sin on asa l n eop lasmin a 4 5-y ea r-o ld m an. U n enh anced co ron al CTscan dem ons tra tes an aggressive sino nasa l m assth a t e rodes the lam ina pap yracea an d invadesthe o rb i ts ( stra igh t ar row s). Th e m ass alsoerodes the sku ll b ase and ex tend s in tracran ia lly(cu rved arrow ). T he p resence of the in trasinu sa rea of inc reased a tten ua tion sugg es ts a ben ig nin flamm atory proce ss.

- .* 1Figure 4 . D iffuse s inonasal po ly pos is m im ick-in g alle rg ic fun gal sin usit is in a 2 8-y ear-o ldm an. C oro na l unenhanced C T scan show scom plete opac ifica tion of th e m ax illa ry ande thm oid sinu ses. T hem e are in tra sin us are as ofh igh at ten uation s im ilar to tho se in F igu re 2 .N ote the th ic ken ing o f the w alls o f th e m axil-la ry s inu s (a rrow s) . T his th ick en ing w as con -firm ed on bon e-a lgo rithm scan s. Endo sco pyshow ed d iffuse sinonasa l po lyp osis w itho u tev id enc e o f a llerg ic m ucin . N o fung al h yph aew ere iden tified a t h is to lo g ic eva lua tio n .

sen ts an imm unolog ic , rath er than anin fec t ious , d iso rder. A ltho ugh the exac tpa tho physio lo gy rem a ins a m atte r o f con-jec tu re , it is p ostu la ted tha t the pa tho-ph ysio log y o f a lle rg ic fu ngab sinus itis iss im ila r to tha t o f a lle rg ic b ronchopu lm o-nary asperg illo sis , invo lv ing bo th imm e-d ia te an d de layed h ypersen sitiv ity (3 ).


5/6

a. b . c.

Vo lum e 207 # { 1 49 }um ber 2 CT o f A lle rg ic F un ga l S in us itis #{149}21

Figure 5 . (a , b ) C T scan s and (c ) M R im ag e of a lle rg ic fu nga l s inus itis in a 38-y ear-o ld m an . (a ) A x ia l unenh anced bone-a lgorithm C T scan sh ow s anexpans ile m ass th at invo lves the ethm oid an d sp heno id s inuses . T he d iffuse e ros ion of the w alls o f th e sp heno id sin us (a rrow s) sugges ts a neop lasm .(b ) So fttis sue-a lgor ithm unenhanced C T scan sh ow s d iffuse in trasinus a reas o f in creased a ttenu ation . T h is find in g favo rs a d iagn osis o f a lle rg icfu nga l sin usi tis ov er a d iag no sis of s ino nasal n eop lasm . (c ) A x ial T 2-w eigh ted M R im ag e (3 ,00 0 /9 0 ( rep etit ion tim e m sec /echo tim e m secj)dem ons tra tes d iffuse a reas o f signa l in tens ity lo ss w ith in th e spheno id and r ig h t e thm oid s inuses . N o te how the ex ten t o f d isease is sub stan tiallyund eres tim ated in c as o pposed to tha t in a or b . T he s ig na l in tens ity loss is like ly due to a com bina tion of an absen ce o f free ly m obile p ro ton s and thepresen ce o f h eav y m etals w ith in fu nga l concre tions .

Pa tien ts w ith a lle rg ic fu nga l s inusitis o f-ten hav e a lle rg ic rh in itis, a s thm a, eo sino-ph ilia, and eleva ted to ta l and fun gus-spe-cific imm unog lobu lin E concen tra tion s (1 ).T hese assoc ia ted fin d ings a re bes t d iag nosedby m ean s o f a lle rg ic tes ting , w hich inc lu dessk in and rad io ab bergosorben t tes ting (1 ).H ow ever, th ese fin d ings m ay no t a lw ay s b eiden tif ied in pa tien ts w ith a llerg ic funga lsinus itis (6 ) . T h is m ay be reba ted to the fac ttha t a m ajo rity o f pa tien ts are trea ted byo to la ryngo lo g ists w ho do no t cons id er th ed iagnos is b efo re trea tm en t. T hus , in -dep thp resu rg ica l alle rgy tes ting is o f ten no t per-fo rmed during th e exam ination of th esepa t ien ts .

M ann ing e t al (2 3) sugges t tha t severa lrela ted fac to rs a re necessary fo r th e deve l-o pm ent o f a lle rg ic fun ga l sin usitis. In i-t ia l ly , an atop ic ind iv id ua l in ha les fung i,w h ich com e to res t w ith in a paranasa ls inus . The presence of th is fung al an ti-g en ic s tim u lu s inc ites a G el and Coom bstyp e I (imm unog lobu lm n E -m edia ted ) andt ype III (imm une-com pbex-m ed ia ted ) in -f lamm atory resp onse, resu lting in o bstru c-tion of a s in us o stium and m uco stasisw ith in th a t pa ranasab sinu s. W ith in th isenv ironm ent, th e inc iting fungu s con tin -ues to pro life ra te , fu rthe r ex acerba tingimm unolog ica lly m ed ia ted in flamm a-tion . E ven tua lly , eo sinop h ilic a lle rg ic m u -cm , in com bina tion w ith p ro life ra tingfunga l hyphae and po lypos is, g ive rise toan ex pand ing s inus , y ie ld ing the charac -te ris tic c lin ica l p ic tu re o f a lle rg ic fung a l

s inus itis . T hu s, the trea tm en t o f a lle rg icfunga l sinus itis d iffe rs from other typ es offu nga l s in usitis and cons ists o f the ora l o rtop ica l adm in istra tion of p redn iso ne af-te r su rg ica l d#{233}bridem en t. Th e sugges tedtherap y is a 4 -w eek course o f o ra l p redn i-sone fo llow ed by a lon g-te rm course ofshort-ac ting in tranasa l co r ticos tero ids(1 ,7 ) . R ecen t stud y find in gs sugg est th ata llergen imm uno th erapy to dow nregu -ba te the pro duc tion of fu ngus-sp ec ific im -m unog lobu lm n E and decrease the in flam -m ato ry reaction m ay a lso b e beneficia l(1,4).

P reopera tive CT find in gs tha t sugges ta llerg ic fun gal sin usi tis m ay fa cili ta te ob -tam ing the necessa ry labora to ry stud iesrequ ired to estab lish th e d iagnos is. E v erya ttem pt shou ld be m ade to fu lfill thed iagn ostic c rite ria o f a lle rg ic fun ga l sinu s-itis be fo re the in itia tion of ste ro id th e rap ybecause of its inheren t side effec ts (21).T h is is especia lly im po rtan t g iven theprepo nderance of a lle rg ic fung al s inus itisin the p ed ia tric p opu la tion , as rep ortedby o thers (21) . T he presence of C harco t-L ey den crys tals w ith in the tenacio us m u-cm w ill h elp co rroborate the d iagnos is o fallergic fu nga l s inus itis (7 ,22 ). S usp ic ionof a lle rg ic fung a l sin usitis a le rts the pa-th o log ist to eva lua te the h istop atho lo g icspec im en sp ecifica lly fo r th is h is to log icm ark er . S pecia l fu ngab s ta ins m ay b e nec-essa ry to id en tify fu nga l hyph ae th a t m ayno t be seen w ith standard hem atox yb in -eo sin sta in ing (3 ,9 ,24) . B ecause of the

var ie ty and fa stid iou sne ss of the org an-ism s tha t m ay be presen t in a lle rg ic fun-ga l sinus itis , sp ecia l cu ltu re m ed ia m ay bereq u ired fo r g row in g th e sp ec ific fun ga lspec ies (3 ,6 ) .

In summ ary , a lle rg ic funga l sinu sitis, ad istinc t c lin ica l en tity w ith nonspec ificsym ptom s, m ay b e in itia lly sugg es ted byth e CT find ings . O ur resu lts a re cons is-ten t w ith those of sm aller se ries andsugges t th a t th e d iagnos is o f alle rg ic fun-g a l s inus itis m ay be ind ica ted by certainfind in gs a t C T (2 ,7 ,8 ,25 ,26) . W hen pres -en t, these find ings shou ld a le rt the c lin i-c ian to the po ss ib ility o f a lle rg ic fun ga ls in usitis and prom pt the refer rin g phy si-c ian to perfo rm th e o ther s tud ies neces-sa ry to es tab lish the d iag nos is and p lantrea tm en t (2 ,4 ,7 ,11 ,22) .

Refe rencesI . DeSh azo RD , Chap in K , Sw ain RE . Funga l

sinus itis . N E nglJ M ed 1 9 97 ; 3 37 :2 5 4- 25 9.2 . M ann ing SC , M eke l M , F r iese l K , V u itch F ,

M am ple B . C om puted tom ography andm agne tic im ag ing of a lle rg ic fu nga l s in us-itis . L aryn go sco pe 1997; 1 07 :17 0-1 76 .

3 . M orpe th JF , R upp N T , D olen W K , B en t JP ,K uhn FA . F ung al sinus itis : an upd ate . An nA llergy A sthm a Imm unol 1 996 ; 76 :12 6-1 40 .

4 . M abm y RL , M ann ing SC , M abry CS . Im m u-nothem apy in the treatm en t of a lle rg icfunga l s in usitis. O to lam yngo l H ead N eckSu rg 1997 ; 116 :31-35 .

5 . Z inre ich SJ, K enn ed y DW , M ab at J , e t a l.F ung a l sin usitis: d iagnos is w ith CF an d MRim aging . R ad io lo gy 198 8; 169 :43 9-444 .

6. T omm es C , R ao JY , E l-N agga r A K , S im S J,W ebem R S, A ya la AG . A lle rg ic fung al sinu s-


6/6

42 2 #{149} ad io logy May1998 M ukh er jie t a i

it is: a clin ic opa tho log ic s tud y o f 16 ca ses .H um Patho l 199 6 ; 27 :7 93-79 9 .

7. C oreyJP , R om berger C F , S haw GY . Funga ld iseases o f the sinu ses . O to la ry ngo l H eadN eckSu rg 199 0; 103 :1 012-1015 .

8 . A llph in A L , S trau ss M , A bdu l-K arim FW .A lle rg ic fung al sin usi tis: p rob lem s in d iag-no sis and trea tm en t. L aryngo scope 1 991 ;101:815-820.

9 . W aitzm an AA , B irt B D . F unga l s inus itis . JO tolary ngo l 199 4; 23 :24 4-2 49 .

10 . M ann in g SC , S chaefe r SD , C lose LG ,Vuitch F . C u ltu re po sitive alle rg ic funga lsinus itis . A rch O to laryngo l H ead N eckS ur g 1 99 1; 1 17 :1 74 -1 78 .

1 1 . B en t JP , K uhn FA . D iagno sis o f a lle rg icfun gal s inu sitis . O to la ryn go l H ead N eckS ur g 1 99 4; 1 11 :5 80 -5 88 .

12 . Safirs te in BH . A lle rg ic b ro nchopu lm o -nary asperg illo sis w ith obs truc tio n of theupper resp irato ry trac t. C h est 197 6 ; 70 :788-790 .

13 . M illa r JW , Jo hn ston A , L am b D . A lle rg icasperg illo s is o fthe m ax illa ry sinu ses. T ho -ra x 1 98 1; 3 6: 71 0- 71 5.

14 . K atzenste in A L , S ale SR , G reenberg er PA .A lle rg ic asperg illu s sinus itis : a new ly rec -

ogn ized fo rm of s inus itis. J A lle rg y C linIm muno l 1983 ; 72 :89 -91 .

1 5 . R obson JM B , B enn RA y, H oga l PG , et a l.A lle rg ic fung al sinu sitis p resen ting as aparanasa l sinu s tum o r. A u st N Z J M ed1989 ; 19 :351-353 .

1 6 . S om PM , C urtin HD . C hron ic in flamm a-to ry sino nasa l d iseases inc lud ing fun ga lin fec tion s: the ro le o f im ag ing . R ad io lC lin N o rth Am 1993 ; 3 1 :33-4 4 .

I 7 . Som PM . S ino nasa l cav ity . In : S om PM ,Bergeron RT , ed s. H ead an d neck im ag in g .2nd ed . S t L ou is , M o: M osby-Y ear B ook ,1 99 1; 1 14 -1 30 .

1 8 . C en teno PS , B en tson JR , M an cu so AA . C Tscann ing in rh inocerebra l m ucorm ycos isand asperg illo s is. R ad io logy 1981 ; 14 0 :383-389 .

1 9 . S ilve rm an CS , M ancuso AA . Perian tra lso f t- tis sue in filtra tion and its re levance tothe early d etec tion of in vasive fun ga lsinus itis : C T and MR find ing s. A JN R 1998 ;19 :321-325 .

20 . D illon W P , S om PM , Fu lle rton GD . H y-po in tense M R signa l in chro n ically insp is-sa ted s inonasa l sec re tions . R ad io logy1 98 8; 1 74 :7 3-7 8.

21 . K up fe rberg SB , B en t JP . A lle rg ic fun gabsinu sitis in the ped ia tr ic pop u la tion . ArchO to la ry ngo l H ead N eck Surg 1996 ; 122 :1381-1384 .

2 2 . B en tJP , K uhn FA . A lle rg ic fu nga l s inus itis /pob ypos is . A lle rg y A sthm a Proc 1996 ; 1 7 :259-268 .

23 . M ann ing SC , V u itch F , W einberg AG ,B row n OE . A lle rg ic asperg illo sis : a new lyrecognized fo rm o f sinus itis in th e ped ia t-nc popu la tion . L aryngoscope 1989 ; 99 :681-685 .24 . G o ldste in M E A llerg ic fung al sin usitis : anund erd iag nosed prob lem . H osp Prac t1 99 2; 2 7: 73 -9 2.

25 . K um azaw a H , Z ehm S , N akam u ra A . CTfind ings of asperg illo sis in the paranasa lsinu ses. A rch O torh inob aryngo l 19 87 ; 244 :77-83 .

26 . S tamm berg er H ,Jakse R , B eaufo rt F . A sp er-g illo sis o f the paranasa l s inuses : x -rayd iagnos is, h is to pa tho logy , an d c lin ica l as -pec ts . A nn O to l R h ino l L aryngo l 19 84 ;93:251-256 .

Documents

Allergic Fungal Sinusitis - CT Findings