0:01

I'd like to review one more time the categorization

0:04

of cyan nasal fungal disease since it is such an interesting

0:08

topic and can be confusing.

0:11

So we have different levels of aggressiveness

0:14

to the fungal infection.

0:16

It can just be sapr prophetic growth

0:18

where we may see some hyper density on CT scan.

0:22

In the secretions of the perinasal sinuses,

0:25

we can have a fungus ball, also known as a mycetoma,

0:28

or if it's characterized by the aspergillus fungus,

0:33

an asperger that again, is a benign entity

0:37

with no aggressive features or aggressive invasion.

0:41

We also have the allergic fungal rhinoc sinusitis,

0:45

which is the entity that has multiple involvement

0:48

of the sinuses with expansion and polypoid changes

0:51

and has the eosinophilic mucin.

0:54

Then we shift to the invasive types.

0:56

We talked about the acute invasive fungal sinusitis

0:59

where you may have aggressive destruction of the bone.

1:03

We see that necrotic appearance on post gadolinium

1:06

and hand scans as well as dark on the T two wade scan,

1:10

and it may lead to invasion of the cavernous sinus

1:13

and vascular complications usually seen in patients

1:16

who are immune compromised, especially

1:19

patients in diabetic ketoacidosis.

1:22

And we also have the chronic invasive form

1:25

where it's lasting greater than three months

1:27

and the form that may occur in Southeast Asia as well

1:30

as in Africa.

1:34

So here is a MR study showing a patient

1:39

who has a fungus ball.

1:41

You note that the abnormality is bright on the T one

1:44

weighted scan and dark on the T two weighted scan.

1:47

Very characteristic of fungal infection in general,

1:51

but this could be just

1:53

very hyper protein tenacious secretions.

1:56

The fact that we see it without aggressive

1:59

features without invasion in a opacified

2:03

perinasal sinus, in this case,

2:04

the right maxillary antrum would give us the likely

2:08

diagnosis of an asperger, a mycetoma, a fungus ball,

2:12

all these terms used interchangeably.

2:16

The next entity is the allergic fungal sinusitis.

2:18

And I showed you the article

2:20

by Resh Mukherjee on this topic.

2:22

It's a hypersensitivity reaction

2:25

to fungal antigens in a patient who has a predisposition

2:28

for allergies, asthma, et cetera.

2:31

You have accumulation of the allergic mucin with charco

2:36

laden crystals.

2:38

And this entity is one that is again,

2:41

not an aggressive invasive form.

2:44

The five criteria that we say for allergic fungal signs is

2:48

that it's a type one hypersensitivity reaction associated

2:52

with nasal polyps.

2:53

CT scan showing opacification

2:55

of multiple paranasal sinuses, the

2:59

Presence of eosinophilic mucin

3:00

and positive fungal stain on the surface

3:03

of the secretions without aggressive invasion of the

3:08

submucosal or bone.

3:10

So here is an example of allergic fungal sinusitis

3:13

where you see that there's expansion

3:15

of the perinasal sinuses with hyperdense secretions.

3:19

There is some thinning of the bone.

3:22

You may see that this bone loss is present,

3:25

but this is still confined by the periosteum

3:28

and is not aggressively invading the orbits.

3:31

But you could see that expansion in sort

3:33

of a polypoid fashion

3:36

with the hyperdense secretions involving multiple

3:39

of the paranasal sinuses.

3:41

Another example of same hyperdense,

3:44

this is a non-contrast CT scan.

3:47

Hyperdense secretions growing into the nasal cavity

3:50

with a poid change identified by the expansion

3:53

of the airway of the sinus or of the nasal airway

3:59

and this absence of invasion of the adjacent tissue

4:04

allergic fungal sinusitis.

4:07

And then finally, we have the aggressive invasive sinusitis.

4:11

And I wanna date myself if I may.

4:14

This is a report from 1989.

4:18

First author used some about MR findings in Rhino Cerebral

4:23

Mucor Mycosis.

4:24

This is was a study in which you can see

4:27

that there was aggressive invasion of the cavernous sinus.

4:32

On the left side here is a post gadolinium scan in which

4:37

the normal right cavernous sinus enhances.

4:41

But as you can see, the left cavernous

4:43

sinus is not enhancing.

4:44

That's abnormal. And

4:46

that implies cavernous sinus thrombosis.

4:49

And you notice that the lumen of the

4:52

left internal carotid artery is much decreased compared

4:56

to the lumen of the right internal carotid artery

4:59

identifying the vasculitis.

5:01

And this patient, as you can see, went on

5:03

to a stroke involving the left middle cerebral artery

5:07

distribution, seen both on the MRI scan as well

5:11

as ultimately on the CT scan.

5:14

You can also see the aggressive invasion of the orbit.

5:16

So this is aggressive invasive

5:20

fungal sinusitis if it lasts greater than three months

5:23

and continues,

5:25

we're going call it the chronic invasive form.

5:29

So some of you trainees out there probably were not even

5:32

born at the time that this article was published.

5:36

Another example of acute invasive fungal sinusitis.

5:40

Now this is typically seen in the inpatient setting

5:43

where we have a patient who has a fever and maybe leukemia

5:47

or is own chemotherapeutic drugs and they ask whether

5:50

or not there is aggressive invasive sinusitis.

5:53

And what one sees with the arrows here is the infiltration

5:57

Of the perianal fat.

5:58

On the right side, there is some soft tissue swelling also

6:01

anterior to this maxillary sinus.

6:04

Doesn't look all that bad,

6:06

but there is erosion of the medial wall

6:08

of this maxillary sinus.

6:10

And here you can see the invasion of the orbit

6:12

with inflammatory conditions here.

6:15

And ultimately this pattern that you see of the absence

6:19

of enhancement of the traditional mucosa

6:22

of the sinus leading to spread intracranial

6:25

with bright signal intensity on the diffusion wave scan,

6:30

identifying infarcted tissue.

6:32

So always look at the perianal fat on your CT scan in a

6:37

patient who's immune compromised to see whether you have

6:40

invasive fungal sinusitis as a potential complication of

6:44

that primary lymphoma leukemia

6:47

or patient on immunosuppressive drugs.