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Fungal Balls of

Paranasal Sinuses
Our Experience.
Dr. Anjoo A. Choudhary

Definition

Earlier misnomers- Aspergilloma/Mycetoma.


Today by definition, Fungal ball is the presence of
tangled mats of hyphae in one or more sinus cavities.
Its a non-invasive form of fungal rhinosinusitis which
is purely extra-mucosal.
Affects immunocompetent patients.

Fergusson BJ. Definitions of Fungal rhinosinusuitis. Otolaryngologic Clinics of North America. 2000; 33:
227-35.
Klossek JM, Serrano E, Preloquin L, Percodani J, Fontanel JP, Pessey JJ. Functional Endoscopic Sinus Surgery
and 109 mycetomas of paranasal sinuses. Laryngoscope. 1997; 107: 112-7

Epidemiology

Affects only adults mostly elders.


Female preponderance.
NO paediatric cases reported yet.
Humidity plays a role.
Maxillary sinus > Sphenoid sinus.

Dufour X, Kauffmann- Lacroix C, Ferrie JC, Klossek JM. Paranasal sinus fungal ball: epidemiology,
clinical features & diagnosis. A retrospective analysis of 173 cases from single medical centre in
France 1989-2002. Medical Mycology. 2006; 44: 61-7.

Pathogenesis

Most widely accepted pathogenesis theorizes


a deficient mucociliary clearance mechanism
in which fungal organisms deposited in the
paranasal sinuses are inadequately cleared.
Fungal organisms germinate, replicate, and
incite an inflammatory response within the
paranasal sinus.
Represents a tangled collection of fungal
hyphae in a mucoid matrix.

Clinical Presentation
Variable or asymptomatic.
Persistent unilateral post-nasal dischargemost common presenting complaint.
Cacosmia.
Acute presentations are uncommon.
DNE reveals non-specific changes or
mucopurulent, cheesy,clay-like material.

Radiology

CT most reliable examination.

Heterogenous opacification of the involved sinusmost common appearance.


Bony thickening or sclerosis of the sinus walls.
Punctate Calcification within the ball.
Bone erosion in presence of significant inflammatory
reaction.

Signal void on T2W MRI.

Lund VJ, Lloyd G, Savy L, Howard D. Fungal rhinosinusitis. Journal of Laryngology and Otology. 2000; 114: 7680.

CT appearance

Diagnosis

Histopathology NO mucosal invasion.


H & E stain.
Gomori Methenamine silver stain.
Cultures positive in only 20-50% cases due to low
viability of fungi.
Aspergillus- most common agent.
A. fumigatus
A. flavus
Scedosporium

Aspergillus as seen on Gomori


Methenamine silver stain-

45 degree branching

deShazos et al gave the clinicopathological criteria


for diagnosis of fungus ball1. Radiological evidence of sinus opacification with or without
associated flocculent calcifications.
2. Mucopurulent, cheesy or clay-like material within a sinus.
3. A matted, dense conglomeration of hyphae separate from but
adjacent to sinus respiratory mucosa.
4. A chronic inflammatory response of variable intensity in the
mucosa adjacent to fungal elements. This response includes
lymphocytes, plasma cells, mast cells and eosinophils without an
eosinophil predominance or a granuloma response. Allergic
mucin is absent on haematoxylineosin stained material.
5. No histological evidence of fungal invasion of mucosa,
associated blood vessels, or underlying bone visualised
microscopically on Gomori methenamine silver or other special
stains for fungus.
Deshazo RD, Chaplin K, Swain RE. Fungal sinusitis. New England Journal of Medicine. 1997;
337: 254-9.

Treatment
Surgical-

Endoscopic guided endonasal widening of involved sinus


ostia.
Complete Removal of fungal ball.
Aspiration of fungal debris away from mucous membrane.
Medical-

Not required in immunocompetent.


In immunocompromised, systemic antifungals or observant
treatment.

Fergusson BJ. Definitions of Fungal rhinosinusuitis. Otolaryngologic Clinics of North America. 2000; 33: 227-35.
Klossek JM, Serrano E, Preloquin L, Percodani J, Fontanel JP, Pessey JJ. Functional Endoscopic Sinus Surgery and 109 mycetomas of paranasal sinuses. Laryngoscope.
1997; 107: 112-7.

Prognosis

Excellent.

Relapse or recurrence is exceptional.

Usually due to residual debris.

Long term follow up not necessary.

Dufour X, Kauffmann- Lacroix C, Ferrie JC, Karkas A et al. paranasal sinus fungal ball & surgery: a
review of 175 cases. Rhinology. 2005; 43: 34-9

Our study of 11 cases


6 were females, 5 were males.
1 case was immunocompromised while rest were
immunocompetent.
1 case with oroantral fistula and 1 with post traumatic
maxillary fracture and plating.
1 case of sphenoid sinus fungal ball, 1 case of maxillary
with ethmoid sinus involvement and 9 cases of pure
maxillary sinus involvement.
All treated by endoscopic removal n widening of sinus
ostium.
Oral Itraconazole was given only in cases showing bone
erosion.
No recurrance.

CASE 1Pre-operative CT scan

Pre-operative MRI

T1W TSE COR PC

T1WTSE
TSEAXIAL
AXIALPC
PC
T1W

Post-operative DNE

CASE 2Pre-operative CT scan

Post-operative CT scan

Post-operative DNE

CASE 3Pre-operative CT scan

Post-operative CT Scan

Post-operative DNE

CASE 4Fungal colonisation over an


inflammatory polyp of Rt maxilla with
palatal erosion in immunocompromised
pt

Video

To conclude

Fungal Ball of paranasal sinuses are extramucosal collection of fungal hyphae.


Involves only 1 or more sinus cavities.
Affects immunocompetant hosts.
Aspergillus is most common species.
Treatment is essentially by complete
removal of fungal ball endoscopically.

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