Clinical and Endoscopic Findings

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Patients with maxillary sinus fungus ball generally complain of symptoms similar to those of a chronic maxillary sinusitis (unilateral nasal obstruction, purulent rhinorrhea, cacosmia, and facial pain), even though the disease may silently progress for a long time. When the fungus ball is located in the sphenoid sinus, vertex headache is the main complaint reported by the patient, while nasal symptoms may be less evident.

Nasal endoscopy often shows nonspecific changes as medialization of the uncinate process, edema of the mucosa of the ostiomeatal complex or of the spheno-ethmoid recess, with thick mucous or mucopurulent secretion outflowing from the middle or superior meatus, respectively. Sometimes, the fungus ball may become evident in the middle or superior meatus or in the nasal fossa. Its appearance varies from a friable material of greenish, brownish, or grayish color to a thick material with a "pudding-like" consistency (Fig. 6.16).

Endoscopy Fungal
Fig. 6.16. Intraoperative view of left nasal fossa (0° rigid endoscope). After uncinectomy, a fungus ball (FB) filling the maxillary sinus is detected. Choana (Ch); middle turbinate (MT); nasal septum (NS)

Eosinophilic fungal rhinosinusitis generally causes bilateral nasal obstruction, watery or mucopurulent rhinorrhea, anosmia, facial pain, and headache. Proptosis and diplopia may seldom be observed as a consequence of lamina papyracea resorption and compression of orbital content by ethmoid disease, while neurologic symptoms due to skull base erosion are a less frequent complaint.

Patients with eosinophilic fungal rhinosinusitis generally had several nasal polypectomies, and bronchial asthma has been reported in more than 50% of cases. Nasal endoscopy displays an edematous and inflamed mucosa, multiple polyps and a thick, viscous secretion, described as "peanut butter" in one or both nasal fossae.

According to Yagi et al. (1999), who reported their experience on 43 Sudanese patients affected by granulomatous fungal rhinosinusitis, symptoms and signs more frequently observed were nasal obstruction with purulent rhinorrhea, headache, swelling of the medial canthus, of the forehead, or of the cheek, proptosis and visual disturbances. The ethmoid was more frequently affected, followed by maxillary and frontal sinuses. Nasal polyposis may be the only visible sign at nasal endoscopy in about 40% of cases. Other endoscopic findings are gelatinous gray-green oil rhinorrhea and firm rubbery tissue, brownish in color, occupying the nasal fossa.

Signs and symptoms of chronic invasive fungal rhinosinusitis are quite similar to those reported by patients with the granulomatous form. At nasal en-doscopy, nasal polyposis is a rare occurrence, while a pale and edematous mucosa, not bleeding during debridement, with concomitant mucosal and bony necrosis, may be observed.

Finally, acute fulminant fungal rhinosinusitis usually presents in an immunocompromised patient with nonspecific signs and symptoms mimicking an acute rhinosinusitis. However, pathognomonic symptoms may rapidly arise, such as black nasomucosal spots, severe facial pain and cheek swelling, epistaxis, headache, ophthalmoplegia, proptosis, and signs of endo-cranial invasion.

At endoscopy, nasal mucosal changes may be observed, reflecting ischemia induced by fungal vasculitis (Fig. 6.17). Early, erythematous or edematous mucosa becomes dusky or necrotic, before progressing to ulceration beneath an eschar. Crusting may overlay a gangrenous, insensitive inferior turbinate. According to de Carpentier et al. (1994), the last sign precedes the rapid onset of facial swelling, orbital symptoms, and systemic dissemination, with involvement of the lungs, liver, and spleen.

Legionella Pneumophila Grocott Lung
Fig. 6.17. Acute fulminant fungal rhinosinusitis. Fungal hy-phae (arrowheads) are present within the lumen and the wall (arrow) of a vessel. Necrotic tissue (NT) is also visible. (Grocott specific histochemical staining). Original magnification 40x

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