Solitary Fungus Ball of the Sphenoid Sinus

doi:10.4236/ijohns.2013.26047

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International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 228-231

Published Online November 2013 (http://www.scirp.org/journal/ijohns)

http://dx.doi.org/10.4236/ijohns.2013.26047

Open Access IJOHNS

Solitary Fungus Ball of the Sphenoid Sinus

Faiz Alouni, Yousof Yousof, Shahram Talebian Khorasani

University of Tishreen, Lattakia, Syrian Arab Republic

Email: [email protected], [email protected]

Received July 18, 2013; revised August 15, 2013; accepted September 10, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

A 50-year-old woman with long standing nonspecific disturbing headaches of the mid-face and rear of the head plus

retro-orbital pain for about one year duration was proved to suffer fro m the fungus ball invo lvement of the left sphenoid

sinus after operation. The diagnosis was established by histopathologic examination of the specimen removed at the

time of operation.

Keywords: Nonspecific Headaches; Retro-Orbital Pain; Fungus Ball; Sphenoid Sinus

1. Case Presentation

A 50-year-old woman, living in the coastal city of Lat-

takia—Syrian Arab Republic, developed chronic head-

aches of nonspecific nature for more than a year before

referring to our ENT clinic in Al-Asad university hospi-

tal. She was complaining of nonspecific headaches and

retro-orbital pain that have affected her life and work to a

great extent. During the time and before referral to our

clinic, she had seen many doctors including ENT spe-

cialist but she had been diagnosed as having psychologi-

cal headaches and/or as a tension headaches of natural

etiology, partly pointing to the stress and hard work she

had. She had been given analgesics and painkillers of

different natures but indeed with no benefit. She also

sought neurologic consultations prior to ENT examina-

tion, but they found no clue whatsoever pointing to

sphenoid pathology. So she was finally referred to our

clinic for furt her worku p and poss i b le diagnosi s.

Upon inquiry, she did not give us any prior history of

hypertension, diabetes mellitus, any hereditary or occu-

pational disorder, as well as any disease or medicines

causing immunosuppression. In physical examination and

all body systems including neurologic examinations, we

found no clue to indicate pathology in the sphenoid sinus

at first and also the rest of the physical examination

proved quite normally. Nevertheless, ENT examination

did not show any significant finding. She underwent

complete blood test and chemical analyses to rule out any

systemic problems and the results of tests were negative

and unrevealed of any predisposing factors or comorbid-

ity elements. To reach a diagnosis and take into account

the possibility of sinus involvement, CT scanning of the

head was done (Figure 1) that showed a radio-opaque

mass in the left sphenoid sinus. Taking into account the

physical examination, lab an alysis and CT result (Figure

1), our preliminary diagnosis was fungal involvement of

the sphenoid sinus.

2. Discussion

2.1. Clinical Presentation

SFB produces symptoms as a result of mass effect and

paranasal sinus obstructio n. Medical attention is typ ically

sought for symptoms consistent with Chronic Rhinosi-

nusitis, although the extensive duration and refractoriness

to medical therapy of a patient’s facial pain, headache,

nasal airway obstruction, chronic cough, or purulent rhi-

norrhea may be indicative of a more unusual process.

Nasal endoscopy may demonstrate inflammatory polyp

disease, which is found in only 10% of patients, but is

more likely to reveal normal to mild mucosal inflamma-

tion without other revealing characteristics [1-4].

2.2. Radiology

CT scans are more revealing, yet certainly not diagnostic.

Single sinus involvement is reported in 59% to 94% of

SFB cases, almost always with complete or subtotal

opacification of the involved sinus and frequently dem-

onstrating radiodensities within such opacifications

(41%). Bony sclerosis of the walls of the involved sinus

is common, as radiographic evidence of this bony thick-

ening is noted in 33% to 62% in different case series. In

F. ALOUNI ET AL. 229

Figure 1. CT scan of the patient indicating pathology in the

left sphenoid sinus.

contrast to the bony erosion commonly seen in allergic

fungal sinusitis, similar sinus bony attrition is noted in

only 3.6% to 17% of CT scans of SFB patients. The

presence of isolated sinus opacification on CT scans will

appropriately prompt either further imaging (MRI) or

endoscopic surgery for both diagnostic and therapeutic

purposes [1-4].

2.3. Pathology

The pathogenesis of SFB almost certainly requires the

inhalation of fungal spores and sequestration into a for-

tuitous location within the sinonasal passages. This warm,

humid location in a poorly ventilated paranasal sinus

favors germination and growth as the fungus evades ho st

immune defenses and avoids clearance from the sinuses

by mucociliary transport. Although d ifficult to iden tify in

cultures of SFB specimens, Aspergillus is the over-

whelmingly most common pathogen responsible for the

condition. Histopathologic review of associated sinus

mucosa demonstrates a mild to moderate infiltration of

chronic inflammatory cells in the absence of tissue inva-

sion, granulomas, or allergic fungal mucin. SFB prefer-

entially involves the maxillary sinus (69% to 86% of

cases), and, in as many as 50% of cases, this may be at-

tributable to favorable conditions for Aspergillus growth

as a result of zinc oxide diffusing into the maxillary sinus

from dental paste used in endodontic procedures per-

formed on maxillary teeth [1-4].

2.4. Treatment

SFB is a noninvasive fungal disease that can be ade-

quately treated by complete surgical removal of the fun-

gal ball and thorough irrigation of the involved sinus.

Although traditionally addressed through external ap-

proaches, most authors report endoscopic techniques to

be effective in complete extirpation of the disease; how-

ever, trephinations for irrigation or endoscope ports as

well as external approaches should be considered in more

challenging cases. Recurrence rates of 3.7% to 6.8% in

SFB patients treated endoscopically is probably accept-

able, because further removal of SFBs can then be per-

formed through widely patent surgical antrostomies in

the office or operating room setting. Postoperative anti-

fungal therapy is not necessary unless the patient suffers

from comorbid conditions with predispositions to com-

promised immune function. Progression from SFB to

AFIFS, although thought to be unusual, has been re-

ported in high-risk patients, patients with blood dyscra-

sias, diabetes, systemic steroids, or other similar condi-

tions associated with immunodeficiency. Antifungal se-

lection in these rare cases should be guided by fungal

histology and culture results to identify the least toxic,

most cost-effective agent available, and topical therapy

Open Access IJOHNS

F. ALOUNI ET AL.

230

with intranasal irrigations shou ld be considered. Ampho-

tericin B formulations should be restricted to cases in

which fungal culture results suggest resistance to imida-

zole antifunga ls [1-4].

2.5. Significance of the Case Report

From literature review concerning diagnosis and man-

agement of isolated sphenoid fungal involvement we

found that this isolated lesion is extremely rare especially

in immunocompetent patients, it is frequently difficult to

diagnose, as patients present with nonspecific symptoms

such as headaches, visual disturbances and cranial nerve

palsies. Diagnosis of the disease is typically not made

until advanced imaging has been developed. Sinus Fun-

gal Ball (SFB), formerly and inaccurately referred to as

“mycetoma” best typifies noninvasive fungal disease of

the paranasal sinuses. This disease state was first de-

scribed by Mackenzie in 1893 and has only been recently

well-characterized, most likely as a result of the small

size of reported case series and the infrequency with

which physicians encounter this condition in their daily

practices. SFB results from sequestration within a para-

nasal sinus of densely tangled, concentrically arranged

masses of fungal hyphal elements in the absence of mu-

cosal invasion or granulomatous reactions [5-18].

3. Our Approach to Treatment

Following physical examination and after receiving the

result of lab and imaging diagnostic workups (Figure 1),

we decided to undertake FESS (Functional Endoscopic

Sinus Surgery) at Al-Asad hospital in Lattakia using

computer assisted navigation (Figure 2) to remove the

pathology most probably differentiated as a fungus ball.

At the time of the operation, we noticed that the frontal

bony part of the sinus was completely destroyed by the

fungus, however, other walls of the left sphenoid sinus

remained intact. The sinus approached only endoscopi-

cally and the fungus ball completely removed as can be

seen by the serial pictures taken by Navigation system

and the endoscopic camera equipment (Figure 2). The

patient was discharged from the hospital after 48 hours

without any complications and the histopathologic report

of the mass later showed that the fungus ball composed

of Aspergillus Nigra (Figure 3).

4. Follow Up

The patient was then followed up for a period of 6

months and all headaches and problems which she was

complaining about at the time of presentation were total ly

resolved, and on nasal endoscopy undertaken a month or

so after the operation, the following picture was taken

from the sphenoid sinus, showing that it is free from any

Figure 2. Pictures taken at the time of the operation of the

patient wit h soli tary fungus ball of the left sphenoi d si nus with

navigation equipment.

Open Access IJOHNS

F. ALOUNI ET AL.

Open Access IJOHNS

231

Figure 3. Histopathologic examination of the specimen taken

from left sphenoid sinus.

Figure 4. Nasal endoscopy underta ken a mo nth or so after the

operatio n.

recurrence or re-establishment of the fungi (Figure 4).

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