Paranasal sinus fungus ball: epidemiology, clinical features and diagnosis. A retrospective analysis of 173 cases from a single medical center in France, 1989–2002

Medical Mycology February 2006, 44, 61
/67 Paranasal sinus fungus ball: epidemiology, clinical features and diagnosis. A retrospective analysis of 173 cases from a single medical center in France, 1989 2002
/ Over the last decade, we have observed a high frequency of Aspergillus rhinosinusitis in french medical centers. The epidemiological data, clinical presentations, radiology, mycology and histology results of 173 consecutive patients with paranasal sinus fungus balls who were admitted from 1989 to 2002 have been reviewed. The most common symptoms included purulent nasal discharges and nasal obstructions, with the maxillary sinus being the most common site of infection (152 cases, 87.8%). Computed tomography scans (CT scan) were performed in 92% (159/173) of the cases and heterogeneous opacities were observed in 132 patients (83%). Histology examinations were performed in all cases and proved positive in 162 patients. Fungi were recovered, mainly Aspergillus fumigatus, from samples of 50 patients, while specimens from the remaining 123 patients were negative. Since no specific clinical sign could be found, a diagnosis of fungus ball is frequently made after a long term symptomatic period. CT scan findings of metallic or calcified densities within an opacified sinus cavity are highly suggestive of a fungus ball, but mycological and histological studies are essential to confirm the diagnosis. Treatment consisted of functional endonasal sinus surgery and was successful in 172 out of 173 cases. Keywords Chronic rhinosinusitis, fungus ball, aspergillosis, fungal sinusitis, Aspergillus fumigatus Introduction The incidence of fungal rhinosinusitis in the immunocompetent population has been increasing over the past decade. Several different clinical presentations can be distinguished, including acute and chronic invasive fungal infections, as well as non-invasive fungal sinusitis including fungus ball and allergic fungal sinusitis [1
/3]. Received 26 December 2004; Accepted 17 June 2005 Correspondence: X. Dufour, Department of Otorhinolaryngology
/ Head & Neck Surgery Centre Hospitalo-Universitaire, Poitiers, BP 577
/ 86021, Poitiers Cedex, France. Tel: 33 5 49444328; Fax: 33 5 49443848; E-mail: – 2006 ISHAM In France, fungal balls are the most frequent noninvasive mycologic sinusitis reported [4
/6]. Its incidence, prevalence, as well as its risk factors are still unknown. However, the presence of dental paste in the maxillary sinus has been put forward as a factor involved in this infection [7
/9]. The clinical presentation of fungus balls is non-specific and asymptomatic cases have also been observed [5,7]. The endoscopic nasal examination is usually normal but oedema or purulent secretion may be observed [5,7]. The typical computed tomography (CT) scan presentation may include heterogeneous opacities associated with discrete calcification or metallic densities within the involved sinus cavity [10]. The maxillary sinus is the most DOI: 10.1080/13693780500235728 X. DUFOUR*, C. KAUFFMANN-LACROIX$, J. C. FERRIE%, J. M. GOUJON§, M. H. RODIER$ & J. M. KLOSSEK* *Department of Otorhinolaryngology
/ Head & Neck Surgery, Centre Hospitalo-Universitaire, Poitiers, BP 577
/ 86021, Poitiers Cedex, France, $Laboratory of parasitology and medical mycology, Centre Hospitalo-Universitaire, Poitiers, BP 577
/ 86021, Poitiers Cedex, France, %Radiology department, Centre Hospitalo-Universitaire, Poitiers, BP 577
/ 86021, Poitiers Cedex, France, and §Histopathology department, Centre Hospitalo-Universitaire, Poitiers, BP 577
/ 86021, Poitiers Cedex, France 62 Dufour et al. Materials and methods The current retrospective series from a single university medical center (from 01/01/1989 to 12/31/2002) was based on the retrospective review of the medical files, the operative charts and the histopathological reports of 173 consecutive patients diagnosed with paranasal sinus fungus balls confirmed by histopathology and mycological analysis. A review was undertaken of all patient information including age, gender, geography, previous surgery, previous dental care, location of infection, nasal endoscopy and CT scan results. Histopathological examination were performed on fungus balls with Gomori methenamine silver staining and showed numerous entangled hyphae with 458 branching. Mucosa biopsy was performed only in cases in which the fungal etiology were in doubt (N /20). Mycology examination consisted of direct smears to observe filamenteous fungi and fungal culture on Sabouraud dextrose agar medium (Bio-Rad, Marnes La Coquette, France), with or without chloramphenicol (Bio-Rad), incubated at 278C and 378C for 3 weeks. Galactomannans were detected in 34 cases in the supernatant of mashed fungus ball with the Platelia Aspergillus kit [12]. The latter consists of an immunoenzymatic sandwich microplate technique using rat monoclonal antibody EBA2 (sensitivity limit, 1 ng/ml). In addition, the Pastorex Aspergillus kit, involving an agglutination technique using latex particles coated with monoclonal antibodies (sensitivity limit, 15 ng/ml) was employed in 34 cases. Results Epidemiology and clinical presentation All patients were clinically healthy and none had had any previous or concomitant history of pulmonary aspergillosis. The gender, age distribution, and living area of the patients are presented in Table 1. Four patients were clinically identified as asthmatic and 23 as atopic. As depicted in Table 2, most patients suffered from purulent nasal discharges, facial pain and chronic nasal obstructions. Endodontic treatment with intracanal or dental fillings was found in 131 out of 173 patients but homolateral overfilling was suspected in only 18 cases (10.4%). The distribution of fungus balls within paranasal sinuses among the 173 patients is presented in Tables 3 and 4. Pre-operative nasal endoscopy performed on all patients, revealed a swelling of the mucosa and purulent nasal discharges for 76 and 73 patients, respectively. The remaining 29 patients had a normal nasal endoscopy. None of the patients received preoperative oral or topical nasal steroids. Radiology results CT scans were performed on 92% (159/173) of the patients and various opacities were observed (Table 5). The results ranged from isolated sinus opacification, with or without discrete calcification or metallic densities (Figs. 1 and 2), to a pseudotumor appearance (Fig. 3). The most common observation (80%) was a completely opacified sinus cavity containing calcification or metallic densities surrounded by spiculated or linear microcalcifications. This was followed in frequency by a thickening of the walls of the involved sinus (Fig. 4). Evidence of bone erosion or remodeling was present in 4 patients. Histopathology and mycology The surrounding connective tissue demonstrated large areas of interstitial inflammatory mononuclear cells, including lymphocytes, plasma cells and/or mastocytes. In contrast, (...truncated)