PICTURE OF RADIOLOGY rhinosinusitis MUSHROOM

PICTURE OF RADIOLOGY rhinosinusitis MUSHROOM

By:
Tutut SRIWILUDJENG T.
Dr. Wahidin Sudiro Husodo Mojokerto

INTRODUCTION
Fungal infections of the nose paranasal sinuses incidence began to increase in this decade, in several studies mentioned 10% of patients filled with fungal rhinosinusitis requires either conventional surgery such as Caldwell Luc or functional endoscopic sinus surgery (BSEF).Most patients with chronic sinusitis fungal infection. Increasing cases of fungal rhinosinusitis cases often with the use of broad spectrum antibiotics and the use of either systemic or local corticosteroids are not rational, but it is also associated with the disease - disease of immune response disorders such as diabetes mellitus, AIDS, and so forth.Fungal rhinosinusitis is rhinosinusitis difficult type disembuhkkan completely. For exact diagnosis, apart from any additional clinical examination is required as well as serology, histopathology and radiology. Radiological examination, especially CT scan (Computer Tomography scanning) is required to evaluate the extent of disease so that helps the operator in directing the operation according to the extent kealinan found.This paper will convey a picture ami radiologist on fungal rhinosinusitis, examination techniques and specific picture of an important note on rhinosinusitis fungi. Because in some cases obtained similar picture of a malignancy that is accompanied by bone destruction.
1. Definition and classificationFungal rhinosinusitis is an infection of the nose and paranasal sinuses that cause hypersensitivity reaction to tissue damage and bone destructionThere are several types of fungal rhinosinusitis division: 1. Acute (fulminant / invasive) 2. chronic (indolent / invasive) 3. misotema 4. allergic fungal sinusitis.Some fungal rhinosinusitis divided into invasive and non invasive. Non-invasive fungal rhinosinusitis consists of sinonasal mycosis superficial; misotema (fungal ball) and allergic fungal sinusitis (SAJ). While that consists of invasive fungal sinusitis acute (fulminant) fungal sinusitis and chronic (indolent / slow).Rinositis non-invasive fungus can occur in patients with good immune status, rarely cause tissue invasion and bone destruction in the long term.Invasive fungal rhinosinusitis is an opportunistic infection that occurs in immunocompromised patients such as AIDS, leukemia, diabetes mellitus, are undergoing radiation or chemotherapy. In these circumstances, the fungus invades virgin vessels around the nose and paranasal sinuses arise as a result of tissue damage and bone destruction.
2. DiagnosisFungal rhinosinusitis diagnosis is established by anamnesis, physical examination, examination radiologinya, immunological and mycological examination. Symptoms - symptoms that can arise in the form of fungal rhinosinusitis: clogged nose, rinore, pembauan disorders, sefalgi, proptopis, visual impairment, neurological deficit, seizures and sensory disorders.Physical examination including nasal endoscopy picture form: fungal tufis, rice polyps, mucous and debris kehitman, granulation, allergic mucin, secret browned and soft cheese-like material. Immune status of patients plays an important role in fungal rhinosinusitis. Patients with diabetes mellitus, acute leukemia, lymphoma, aplastic anemia, multiple myeloma, patients who are undergoing organ transplants, systemic steroids, radiation, malnutrition. Invasive fungal rhinosinusitis causes.Immunological examination found a positive skin test to fungal allergens, increasing the number of blood eosinophils, an increase in total serum IgE, increased IgE and IgG specific to the fungus.It takes approximately 1-4 weeks to conduct a fungal culture so as to identify the exact type of fungus that is found. Some types of fungus that can ditemunkan on fungal rhinosinusitis: Aspergillus fumigatus, Aspergillus flavvus, Aspergillus niger, Alternaria, Bipolaris, Cnadida, Curvularia, Fusarium, Paecilomyces, Penicillium, Psedallescheria boydii, Rhizopus / Mucor and Scopulariopsis.Histopathologic examination of the biopsy is needed to assess the presence of tissue invasion is a sign of the emergence of invasive fungal sinusitis, often occurs in immunocompromised patients.Radiology examination is sufficient additional checks skelter in fungal rhinosinusitis diagnosis. The examination included plain head, CT scan and MRI head plain less specific to assess fungal rhinosinusitis but still very necessary to start screening patients with rhinosinusitis, in addition to low fees compared to CT scan and MRI and can be done in almost every hospital.
3. Fungal rhinosinusitis radiological pictureTypes of radiological examinations can be done to see abnormalities in the paranasal sinus area are:
3.1 Plain headPlain head is the initial examination of paranasal sinus disorders. In patients with fungal rhinosinusitis both invasive and non invasive, plain reading of the head can only be identified thickening of mucosal (mucous membrane), liquid limit with the air forming a flat surface (air-fluid level) or perselubungan that covers part or in whole cavity and partial structure bone is visible. The presence of erosion, paranasal sinuses or bone destruction is not apparent because of blocked perselubungan picture as well as water-fluid level.Type of inspection plain head in assessing paranasal sinuses need to be considered include photographs Waters, Caldwell, submentovertex and lateral head photograph. Compared to CT scans and MRI, plain difficult to distinguish between tumors and polyps infection, but examination in reasonably priced, easy to work, a low degree of radiation than CT scans and almost all hospitals mampunyai this inspection facilities. At least 3 year olds, especially underdeveloped frontal sinus appears to be only a white area so that it looks as though - would be sinusitis.The following table shows the plain head with paranasal sinus shadow that can be evaluated:
Caldwell Waters Submentovertex Lateral PositionSinelamina etmoid papirase &Etmoidalis fovea,Etmoid ant & postSelf-explanatory Only etimoid ant Less clear unobstructedPalate, septumRice & SinusfrontalSineOnly part of the inferior maxillary best position,Side lateral, medial,Superior and inferior Basis of SinusRelated dgThe roots of teeth &Part of the wall hard palateLateral & basesineSineLooks frontal lineLooks Mukoperiosteal lineMukoperiostial Resesus frontal &DPN Diding sinus Less informativeSineLess informative sfenoid manibula blocked,Best when the mouth is open (Malts) sinus mucosa,Basic sella turcica,Assessing the posterior wall of the baseMouth (below) &Lateral wall
3.1.1 Sinus EtmoidEvaluation of best etmoid sinus using Caldwell's position. The drawback selule etmoid sumperimposed (blocked) with other etmoid selule the back of the skull base. If there is perselubungan hard to determine whether inflammation or neoplasm, but the lamina papirasea and etmoidalis fovea can be seen clearly walauoun not as detailed as CT scans.Waters Photos can only be seen as part of the anterior sinus etmoid other etmoid obstructed sinus fossa nasalis. Photo submenvertex less clearly illustrates this because of blocked sinuses palate, nasal septum and frontal sinus base.

3.1.2 maxillary sinusRadiological examination of maxillary sinus best use photo waters. Most of the shape asymmetry between right and left. In addition to assessing the maxillary bone pneumatization, photos waters also assess basic orbital wall and zygoma, so that gives enough additional information on the disease of fibrous dysplasia, giant cell tumor and Paget's disease. Plain lateral head is needed to evaluate the maxillary sinus base associated with the roots of the teeth and hard palate, it plays a major role to assess the expansion of tumor / infection of the sinuses. Submentovertex only give an overview of the basic sinus and lateral wall.
3.1.3 Frontal SinusOverview of the frontal sinus can be seen in the photograph Waters and Caldwell. Since its development has been slow, often found frontal sinus aplasia or hipolasia. The important thing to note is that the line is the line that separates mukoperiosteal frontal sinus mucosa with os frontal. In the photo can be seen resesus lateral frontal head-shaped and concave fracture picture of the front wall of the frontal sinus if there is any history of trauma. Looks picture Diding frontal sinus osteomyelitis in a few cases of Paget's disease. Photo submentovertex not provide information on the frontal sinus.
3.1.4 Sinus sfenoidBecause of its location surrounded by some of the bone and in nearby cranial base, while also the variation of pneumatization (type konkal small opening and a small opening) it is difficult to evaluate with plain head routine. Combined lateral images of head and submentovertex enough to provide information about the sphenoid sinus abnormalities. The best position to assess this is the position of the sphenoid sinus Maltz (Waters positions with open mouth).Photos assess lateral sinus mucosa, planum sphenoid base and back wall between sinus. Position submentovex sphenoid sinus rate from the bottom (floor of the mouth) can thus assess the extent of disease to the lateral.The thickness of normal mucosa between 1 - 2mm, looks gembaran multibosselated radiodensity on multiple polyps. Where the density of the sinus with bone erosion of the sphenoid sinus, it should be suspected of malignancy.
3.2 CT scan (Computer Tomography scanning)CT scan is an examination of the picture more clearly radiologist to assess bone architecture - Maxillofacial bone, soft tissue and paranasal sinus sphenoid and ethmoid sinuses, especially compared to plain head. For sinus disorders due to fungi, it is not necessary to use contrast unless there is a sign - a sign komplikasi.intrakranial, periorbital sellitis or abscess. On the contrary before the CT scan are given antibiotics and anti-inflammatory for adequate description of soft tissue and sinus mucosa appear more clearly. CT scan is the gold standard examination prior to BSEF.CT slices used were coronal, axial CT and sagittal CT with soft tissue techniques (soft tissue settings) as shown in Figure 1 with ketabalan 3-5 mm, the CT examination in hospitals scanrutin Mojokerto ketebalnnya 10mm.
Figure 1: Sliced ​​coronal, axial and sagittalThere tambahn slices of spiral CT slice CT which is a combination of coronal and axial CT. With spiral CT, provides ease of surgeons in assessing the 3 dimensional aspect ostiomeatal complex (OMC) for reducing the appearance of metal artifacts such as tumpatan teeth (amalgam).Paranasal sinus mucosa of normal thin that sometimes - sometimes not visible on CT scan, only the picture of bone and air. In case of mucosal thickening and soft tissue is a process that occurs in sinus inflammation caused by infectious or non infectious process, fibrosis or neoplasm. The picture of inflammation in fungal sinusitis and air-fluid level was evident on coronal slices. Fungal Sinusitis often occurs in the maxillary sinus and sinus etmoid, rarely occur in the frontal and sphenoid sinuses. CT scan picture of fungal sinusitis varies according to the distribution, non-invasive or invasive.
3.2.1 CT scan is non-invasive fungal rhinosinusitisNon-invasive fungal rhinosinusitis are common picture of aspergillosis in allergic fungal sinusitis. Looks hiperdense shadow on sinus fungal infection aspergillosis, is caused by deposits meineral form of calcium, manganese, magnesium and ferromagnetic elements. Also showed that erosion caused bone remodeling due to pressure of fungal mass, not caused by fungal invasion or destruction due to fungi, shown in Figure 2.

Figure 2: CT coronal, looking hiperdense mass in the right and left maxillary sinusAlmost 20% of patients with allergic fungal sinusitis obtained bone erosion on CT scans, often occurs in the lamina parirasea so to the invasion of the orbita and etmoid roof (lamina kibriformis) as in figure 3, 4 and 5.

Figure 3: CT coronal, erosion papirasea lamina and lamina kribosa cause intra-orbital extension and anterior cranial fossa.

Figure 4: Axial CT, klivus erosion caused by sinusitis sfenoetmoid bilateral extension into the posterior cranial fossa.


Figure 5: Axial CT, erosion of the posterior wall of the frontal sinus.Mucosa is a type of fungus that attacks sinusitis sphenoid sinus due to a pile of calcium sulfate, calcium phosphate, iron (Fe), magnesium and manganese then on CT scans appear formations funganl ball or a picture similar to onion skin (onion skin appearance) in the form of mass density bone that surrounded the picture with the density of mucosal tissue or soft tissue. As shown in Figure 6.

Figure 6: CT coronal, picture of fungal ball in the sphenoid sinus
3.2.2 CT scan of invasive fungal rhinosinusitisOverview of invasive fungal sinusitis on CT scan-like ferocity which occurred destruction sinus walls and surrounding tissues due to mucormikosis or invasive aspergillosis, as shown in Figure 7. At this early stage looks sinus mucosal thickening without air-fluid level, with advanced bone destruction marked sinus wall due to necrosis of the sinus mucosa.
Figure 7: CT, coronal, the picture of invasive fungal sinusitis-like tumor mass destruction premises medial wall of maxillary sinus.3.3 MRI (magnetic resonance imaging)MRI is helpful in assessing the complications of fungal sinusitis are limited both in extracranial. This is due to have a contrast MRI of soft tissue (soft tissue contrast) better than CT scans, very good to distinguish the lesion / tumor with surrounding soft tissue. In addition, the absence of ionizing radiation cause safe for patients and can be done over and over - again. But less well than the rate of abnormalities in bone scans and CT examination is a long time and a higher cost compared to CT scans. Also udim picture akibaat inflammatory nasal mucosa is similar to udim on nasal cycle. If the suspicion of intracranial or intraorbital complications needed contrast-diethylenetriamine pentaacetic acid gadolinium (Gd-DTPA)There is no specific description fungal sinusitis on MRI, isointense or only slightly hipodense than surrounding tissue as shown in Figure 8. MRI is more useful in assessing neoplasms because it can distinguish tumor mass with disorders due to blockage of the sinus ostium or ostiomeatal complex.

Figure 8: A, coronal MRI, the picture looks hipodense the frontal sinus and erosion due to the mass of the lamina papirasea etmoid B, durameter compression caused by the mass on the frontal sinus.4. SummaryTo make a diagnosis rinodinusitis fungus required a careful history taking, clinical examination, histopathology / mycology, immunology / allergy tests and radiology examinations.Screening patients suspected of having fungal rhinosinusitis still need a plain head with some positions Caldwell, Waters, submentovertex and lateral. Given the CT scan and MRI facilities exist only in the cities - big cities.Preview aspergillosis in fungal sinusitis which looked a shadow hiperdense, whereas invasive fungal rhinosinusitis is similar to the image of malignancy with destruction of sinus walls and surrounding tissue so that the necessary confirmation of the clinical, histopathological / mycology and immunology / allergy test.CT scan bone memeberikan excellent resolution compared to plain and MRI images that is required prior to BSEF.MRI can distinguish soft tissue better than CT scan so necessary in case of fungal invasion into the intracranial.
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