Fungal sinusitis.pptx

fungal
sinusitis

1. Fungal Sinusitis By osama alshaaili R2116

2. Outline Basics Types of fungal sinusitis Management What's new

3. Forms yeast or mold Yeast Unicellular Reproduce asexually by buddingPseudohyphae – when bud doesn’t detach from yeast Mold Multicellular Grow by branching – hyphae

4. Microscopic appearance Septated hyphae Nonseptated hyphae

5. Classifications Noninvasive - Fungus Ball (fungus mycetoma) - Saprophytic fungal infection - Allergic Fungal Sinusitis Invasive - Acute Invasive Fungal Sinusitis - Chronic Invasive Fungal Sinusitis - Chronic Granulomatous Invasive Fungal Sinusitis

6. How to differentiate ? Invasive Presence of fungal hyphae within the mucosa , submucosa, bone, or blood vessels of the paranasal sinuses Noninvasive Absence of fungal hyphae within the mucosa and other structures of the paranasal sinuses

7. Fungal Ball Sequestration of fungal elements within a sinus without invasion or granulomatous changes Presents similar to rhinosinusitis, Cocosmia peanut-butter like appearance Frontal/ Maxillary sinus most common followed by sphenoid sinus Surgical Removal with restoration of drainage of the sinus

8. Saprophytic Fungal Infestation After sinonasal surgery Visible growth of fungus on mucus crusts without invasion Diagnosis: Endoscopic visualization of crusts with fungi Treatment: Weekly nasal endoscopy with removal of crusts until disease process resolves

9. Allergic Fungal Rhinosinusitis Most common form Hypersensitivity reaction to inhaled fungal organisms Typical allergic Mucin Diagnostic criteria (Brent & Khun ) : 1) Nasal Polyps 2)The presence of eosinophilic mucin 3) Characteristic CT 4) + ve Fungal culture and/or smear 5) Fungus-specific IgE is demonstrated 6) immunocompetent 

10. AFRS

11. MRI

12. Microscopic examination Charcot - Leyden crystals

13. Managment Surgical removal of allergic mucin restoration of normal sinus drainage is goal Stepwise management : Topical Steroids Antileukotrienes inhibitors Antifungal Biologics Oral steroids Experemental Therapies

14. Pre-op Steroids Pre-op Anti Fungal

15. High vs low volume Post-op Steroids

16. Oral Antifungal Topical Antifungal

17. Future Therapeutic options aPDT (blue light therapy) Poloxamer gel Povidon iodine 10% irregation Nitric oxide releasing solutions

18. Acute Invasive Fungal Sinusitis Mortality 50 - 80% Typically Immunocompromised patients Two clinical populations - Poorly controlled Diabetics – ususally caused by fungi of order Zymocycetes (Rhizopus, Rhizomucor , Absidia , and Mucor ) - Immunocompromised with severe neutropenia ( chemotheraphy patients, BMT, organ transplants, AIDS) – Aspergillus accounts for 80% of infection in this group

19. Acute Invasive Fungal Sinusitis Spores inhaled = fungus grows in warm, humid sinonasal cavity Fungi invade neural and vascular structures with thrombosis of feeding vessels Mucor causes obliterative vascular invasion leading to ischemia. Necrosis and loss of sensation = acidic environment = further fungal growth Extrasinus extension occurs via bony destruction , perineural and perivascular invasion

20. CT scan Unilateral ethmoid involvement with bone destruction intraorbital spread and proptosis

21. MRI

22. Managment Aggressive surgical debridement and systemic antifungal therapy High doses of Amphotericin B (1-1.5 mg/kg/d) are recommended. Oral Itraconazole (400 mg/d) can replace once the acute stage has passed Reversal of cause of immunosuppression if possible Intracranial spread is most predictive of mortality

23. Chronic Invasive Fungal Sinusitis Slower disease process than acute Biggest difference: Most patients are immunocompetent Usually persistent and recurrent disease Noncontrast CT – Hyperattenuating soft tissue mass withing one or more of paranasal sinuses, bone involvement with or without sclerosis MRI – decreased signal on T1& T2

24. Management Similar to acute – surgical + medical Start with Amphotericin B until can rule out Mucormycosis Best length of treatment not well studied Most recommend 3-6 months of therapy Close F/U and debridement required Biopsy anything that is suspicious as asymptomatic recurrence is not uncommon

25. Granulomatous Invasive Fungal Sinusitis Same entity as chronic invasive fungal sinusitis Primarily found in Africa and Southeast Asia, only few case reports in US Immunocompetent Caused by Aspergillus flavus Characterized by noncaseating granulomas in the tissues