Vol 5(1) (2020) 87-88 | jchs-medicine.uitm.edu.my | eISSN 0127-984X https://doi.org/10.24191/jchs.v5i1.9826
87
Case Presentation
A 65-year-old female with long standing diabetes mellitus presented with left unilateral nasal blockage for 6 months duration. The symptom was progressively worsening causing total obstruction of the left nostril. She also had left greenish thick nasal discharge associated with facial fullness, cacosmia, hyposmia and left epiphora.
Nasal endoscopy showed a polypoidal mass at superior part of left nasal cavity with medialization of left lateral nasal wall and obliteration of the osteomeatal complex and inferior meatus by the mass (Figure 1). The pale mass extended towards posterior nasal cavity but not obscuring the posterior choana.
Figure 1 Endoscopic view of left nasal cavity showing the polypoidal mass with bleeding point (black arrow) and medialization of left lateral nasal wall.
JCHS-CQ-01-2020
An Elderly with Unilateral Maxillary Sinus Mass
Abdul Azim Al-Abrar Ahmad Kailani
1,2, Wan Nur Anis Wan Draman
1, Norasnieda Md Shukri
1, Irfan Mohamad
11 Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia.
2 Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universiti Teknologi Mara, Sungai Buloh, Selangor, Malaysia.
Vol 5(1) (2020) 87-88 | jchs-medicine.uitm.edu.my | eISSN 0127-984X https://doi.org/10.24191/jchs.v5i1.9826
88 Result of the biopsy of the mass was consistent with inflammatory polyp with predominant neutrophilia. Computed tomography (CT) scan of the paranasal sinuses was performed. There was heterogenous enhancing mass occupying the entire left maxillary, frontal, anterior and posterior ethmoid sinuses. Additionally, the left maxillary sinus was widened with erosion of its medial wall and hyperostosis of its lateral wall (Figure 2).
Figure 2 Coronal (A) and axial (B) reconstruction of CT of the paranasal sinuses showing heterogenous mass in the left maxillary sinus with intrasinus calcification within (red arrow) and erosion of its medial wall (blue arrow) and thickened lateral wall (green arrow).
Question 1: Hyperostoses of sinus wall are present in the following conditions except A. inverted papilloma
B. chronic sinusitis C. fungal sinusitis D. acute rhinosinusitis
Question 2: What is the most appropriate clinical management for this patient?
A. Open surgical debridement
B. Intravenous antifungal medications C. Endoscopic sinus approach
D. Oral steroids with intravenous antibiotics
Vol 5(1) (2020) 89-90 | jchs-medicine.uitm.edu.my | eISSN 0127-984X
https://doi.org/10.24191/jchs.v5i1.9826
89 ANSWER TO JCHS-CQ-01-2020
Question 1: D Question 2: C
Discussion
The patient was diagnosed with fungal sinusitis. She subsequently underwent left mega medial maxillary antrostomy and removal of left maxillary fungal ball through pre-lacrimal approach.
Fungal sinusitis is classified into invasive and non-invasive forms. Acute invasive fungal sinusitis, chronic invasive fungal sinusitis, and chronic granulomatous invasive fungal sinusitis are the subtypes of invasive group, while allergic fungal sinusitis and fungus ball (fungal mycetoma) are part of non-invasive fungal sinusitis. Each subtype is unique with different clinical presentation and radiological features. The final diagnosis for our case was fungus ball sinusitis (mycetoma) based on the intraoperative findings.
Fungus ball is an extramucosal mycosis and usually occur in an immunocompetent elderly female. Unilateral maxillary sinus involvement is the most common findings on CT scan [1]. Other characteristic features of fungal mycetoma on CT are dense spot in the centre of the lesion with surrounding bony thickening [2]. The fungal ball also follows the contour of the sinus lumen with intralesional calcifications without presence of air-fluid level. Chen et al reported that more than 70% of cases showed absent air-fluid levels, peripheral bone sclerosis and erosion of the sinus wall by pressure necrosis [3]. In our case, the CT scan findings have all the typical characteristic appearance of fungus ball sinusitis as mentioned above.
Functional endoscopic sinus surgery and removal of fungus ball is the mainstay of treatment with aim to restore the ventilation pathway of the sinuses especially the osteomeatal complex. Rarely, antifungal is needed and curative rate is almost 100% [4]. Recurrence is also uncommon. The commonest isolated fungal culture is Aspergillus spp.
Histopathological examination will confirm the diagnosis by presence of solidly arranged hyphae with no allergic mucin and no invasion of blood vessels. This is important to discriminate a fungus ball from allergic fungal sinusitis and invasive fungal sinusitis respectively.
JCHS-CQ-01-2020
An Elderly with Unilateral Maxillary Sinus Mass
Abdul Azim Al-Abrar Ahmad Kailani
1,2, Wan Nur Anis Wan Draman
1, Norasnieda Md Shukri
1, Irfan Mohamad
11 Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia.
2 Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universiti Teknologi Mara, Sungai Buloh, Selangor, Malaysia.
Vol 5(1) (2020) 89-90 | jchs-medicine.uitm.edu.my | eISSN 0127-984X
https://doi.org/10.24191/jchs.v5i1.9826 90
Learning Points
• Fungal sinusitis has multiple subtypes which behave differently and CT scan can aid on the diagnosis based on characteristic findings of each subtypes.
• Treatment plan is tailored case by case based on the history, clinical examinations and radiological findings.
Functional endoscopic sinus surgery is widely accepted as the surgical approach to fungal sinusitis.
• Prompt diagnosis and treatment may avoid fatal complications which is commonly encountered with invasive fungal sinusitis compared to non-invasive type.
Conflict of Interest Authors declare none.
REFERENCES
1. Gorovoy IR, Kazanjian M, Kersten RC et al. Fungal Rhinosinusitis and Imaging Modalities. Saudi J Ophthalmol.
2012; 26(4):419-426.
2. Pillai S, Bhandarkar AM, Nair SS et al. A Radiological Profile of Fungal Sinusitis. Asian J Pharm Clin Res. 2017;
10(9):331-334.
3. Chen JC, Ho CY. The Significance of Computed Tomographic Findings in The Diagnosis of Fungus Ball in The Paranasal Sinuses. Am J Rhinol Allergy. 2012; 26(2): 117-119.
4. Morpeth JF, Bent III JP, Kuhn FA et al. Fungal Sinusitis: An Update. Ann Allergy Asthma Immunol. 1996; 76(2):
128-140.
Corresponding author:
Irfan Mohamad,
Department of Otorhinolaryngology-Head and Neck Surgery,
School of Medical Sciences,
Universiti Sains Malaysia Health Campus, 16150 Kota Bharu,
Kelantan, Malaysia
Email address: [email protected]