0:00

So this was a case of, uh,

0:02

mucosal thickening involving multiple perinasal sinuses.

0:07

So here I think you can see, you can see the screen share,

0:10

you can see that there's, um, expansion of the perinasal sinuses,

0:14

and there's also some increased attenuation within the perinasal sinuses.

0:19

So this could be a couple of things. You know,

0:22

this could either be sinus disease with multiple desiccated secretions,

0:27

or, um, in this particular case,

0:30

if you have multiple sinuses involved and there's increased attenuation,

0:34

and this is what this disease entity is known as,

0:37

is allergic fungal sinusitis.

0:40

So this is an example of allergic fungal sinusitis.

0:43

So these are all examples of this.

0:45

So the key thing to make the diagnosis is that you see opacification of

0:50

multiple perinasal sinuses, and we can also see increased attenuation, uh,

0:55

within the sinuses as well too. So, um,

0:58

here we can see opacification,

1:00

the ethmoids and the sphenoid sinuses and the increased attenuation within them.

1:05

So, um, the key thing is it's a non-contrast ct. Another example here,

1:10

this patient came in with a possible rhabdomyosarcoma.

1:14

This is back when I was at U N C, so everyone was worried about it.

1:17

But then because this was a non-contrast ct,

1:20

and we can see expansion of the perinasal sinus is the increased in the

1:24

increased attenuation. Then again,

1:26

this is characteristic of allergic fungal sinusitis,

1:29

and I believe I sent you a paper we wrote many years ago on allergic fungal

1:34

sinusitis that, um,

1:36

commented on the characteristic imaging findings. So, um,

1:41

these are typically treated with, uh, surgical resection,

1:44

usually through functional endoscopic sinus surgery. Um,

1:48

the classical appearances like this toothpaste or peanut butter consistency

1:54

of these lesions.

1:55

And oftentimes they're treated with some type of antifungal therapy,

2:00

but it's not the, this is not, um, invasive fungal sinusitis.

2:04

So this is not the typical mucor mycosis that you see. Rather,

2:07

this is more of a benign indolent form,

2:10

and the type of antifungal therapy is something like ketoconazole

2:15

and steroids. So it's nothing super aggressive.

2:18

So this was a diagnosis of, um, allergic fungal sinusitis.

2:23

So I can stop there and, um, you know, happy to take any questions on,

2:27

on this case.

2:29

So the key imaging features is the thinning of the bone

2:34

with high attenuating content,

2:37

Right? So multiple sinus involved expansion of the sinuses and high attenuation.

2:43

So for the invasive fungal sinusitis,

2:46

we look for any increased fat stranding and any soft tissue around the

2:50

sinus. Outside the sinus,

2:53

Yes, exactly. Especially in patients that are at risk.

2:57

So I can share that with you as well too.

3:01

So this is the invasive fungal sinusitis. So, or in early on, it's,

3:05

you really can't tell the difference between invasive fungal sinusitis and

3:09

non-invasive fungal sinusitis. But in patients at risk,

3:12

this is what you look for. You could see this abnormal soft tissue in this case,

3:16

involving the canine fossa and the tego palatine fossa. And then on Mr,

3:21

this is the classical appearance here.

3:23

You can see there's obliteration of fat here in the tego, palatine fossa.

3:27

And then another example here. This is abnormal soft tissue here,

3:31

abnormal soft tissue here, there's no bone erosion. Another example here,

3:35

see the soft tissue here, see the soft tissue there.

3:40

And then eventually this thing just continues to grow and grow and grow.

3:44

So there's a little bit of soft tissue here.

3:46

You don't see it on the opposite side. This was a patient at risk.

3:49

And then this can progress just completely erode the, the sinus here.

3:53

It's extending into the tgal, palatine, vasa,

3:57

and then another example here, a little bit of soft tissue anteriorly,

4:00

and they can just continue to progress. Does that make sense for you?

4:06

Yes. So it is, uh, allergic fungal sinusitis is a precursor for invasive,

4:11

if not treated well.

4:13

No, no. Allergic fungal sinusitis is completely different than invasive fung.

4:18

Different,

4:18

Okay.

4:19

Yeah. Completely different. Yeah. They, although they can be caused by the same,

4:23

um, bugs, if you will, they can be, uh, caused by the same,

4:28

uh, elements, uh, like aspergillus and mucor, et cetera.

4:33

It's a non-invasive form, and the body can,

4:35

it'll can elicit a host response to it.