Role of Computed Tomography in Paranasal Sinuses - A Review Article

Computed tomography is one of the medical imaging tests in diagnosis. Multiple images of the inside of the body get captured in CT, like in traditional x-ray, but in various planes, can reformat the generated images. In CT, more excellent images are captured than in x-rays, especially for soft tissue and blood vessels. Four pairs of sinuses are there in the body, and small openings connect each to the nasal cavity. Out of the four sinuses, the paranasal sinus, a hollow and air-filled space, is located within the bones of the face. A vital role is played by Computed Tomography (CT) in the study of Paranasal Sinuses to diagnose and determine the various diseases related to paranasal sinuses. For example, multiple conditions like inflammatory, malignant neoplastic, and benign affect the paranasal sinus;all these conditions are diagnosed by CT Scans which directly help reduce the mortality and morbidity in patients suffering from diseases that affect the paranasal sinus. Besides this, CT Scans of paranasal sinus before functional endoscopic sinus surgery also help evaluate paranasal sinus disease and many more. The article aims to study the pathologies for which paranasal sinuses are affected and CT features of paranasal sinus diseases. Paranasal sinus computed tomography scans are performed for the measurements of - the volume of the nasal cavity. CT scan is also essential in evaluating anatomical variations to prove the correlation between the extent of disease and disease process in Sinonasal polyposis patients. Also, because of CT, paranasal sinus anatomy is delineated. This is the overview of the role of CT in paranasal sinus study (diagnostic, anatomical). Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Tomographic changes of the paranasais sinuses of patients with Covid-19

Objective: To verify the presence of tomographic alterations in the paranasais sinus of patients diagnosed with Covid-19 and to evaluate the presence of an association between olfactory symptoms and the involvement of these sinus. Method(s): This is an observational cross-sectional study that analyzed computed tomography of the nose and paranasal sinus (SSCT) of patients with Covid-19 regarding the presence of mucous thickening in the paranasal sinus. Patients who underwent RT-PCR examination for detection of Covid-19 (SARS-CoV-2) and TCSPN infection from March 2020 to March 2021 were included. Patients with a history of previous nasosinusal surgery, recent facial trauma, age below 18 years or with incomplete information in medical records were excluded. Result(s): A total of 65 individuals were included, of whom 28 were diagnosed with Covid-19. In tomographic analysis, an association was observed between Covid-19 infection and mucous thickening of the bilateral maxillary sinus (p = 0.038) and mucous thickening of the bilateral ethmoidal sinus (p = 0.005). No significant association was found between mucous thickening of the sphenoid and frontal sinus with virus infection. The complaint of olfactory dysfunction was reported by 20% of the patients, with no association with tomographic alterations or Covid-19 infection. Conclusion(s): Covid-19 virus infection possibly causes an injury to the mucosa of ethmoidal cells due to the inflammatory process resulting from viral infection. The lesion of the mucosa of the ethmoidal sinuses may cause alteration in the drainage physiology of the maxillary sinuses due to blockade of the middle meatal tract - site of drainage of the maxillary sinus - and lead to edema of the mucosa of this sinus. This change in the mucosa of the ethmoidal sinus may also be the cause of olfactory disorders presented by patients, as well as may cause lesions in the olfactory nerve. Keywords: Covid-19;SARS-CoV-2;Anosmia;Tomography;Paranasal sinuses. Copyright © 2022

A RARE PRESENTATION OF COVID-19-ASSOCIATED CENTRAL VENOUS THROMBOSIS

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Due to a wide range of clinical presentations, central venous thrombosis (CVT) is a rare neurologic condition that can be difficult to diagnose. Since the COVID-19 pandemic, more cases of venous thromboembolic events have emerged and been found associated with COVID-19. We detail a potential case of COVID-19 associated CVT. CASE PRESENTATION: A 28-year-old female with past medical history of obesity, polycystic ovary syndrome, recurrent sinusitis, and presumed history of COVID-19 infection with anosmia, ageusia, and sinusitis symptoms three- months prior presented to the hospital with 1-month history of worsening, right-sided pain behind her ear, eye, head, posterior neck and shoulder, nausea, and photophobia, which had worsened in the last 5 days. She initially tried over-the-counter medications with no improvement. Vital signs were unremarkable. Examination was notable for frontal sinus and right postauricular tenderness to palpation. C- reactive protein was elevated at 26.2 mg/L. Non- contrasted brain computed tomography (CT) was concerning for right transverse sinus and superior sagittal sinus thrombosis. Brain magnetic resonance imaging (MRI) showed early signs of cortical edema and venous infarction and findings concerning for right mastoiditis. Intracranial venous MRI showed complete thrombosis of the right transverse and sigmoid sinus, superior sagittal sinus, and most of the superior draining cortical veins. Heparin drip was started. Initial empiric antibiotics for mastoiditis were stopped. Hyper-coagulopathy work-up with beta- 2 glycoprotein 1 antibodies and phospholipid antibodies were negative. As there were no other inciting factors for CVT found and no history of positive COVID-19 test, a COVID-19 antibody immunoassay was obtained and returned positive. The patient did not have a history of COVID vaccination. She was discharged on warfarin and enoxaparin. Anticoagulation was stopped after 6 months with repeat imaging showing resolution of clot burden. DISCUSSION: Usual risk factors associated with CVT are morbid obesity, hormone replacement therapy, oral contraceptive use, hereditary thrombophilia, and pregnancy. Literature on CVT related to COVID-19 is limited. In 41 documented cases, the average age of incidence is 50 years old and median onset of neurological symptoms from initial COVID-19 diagnosis is 7 days [0 to 21 days]. Our patient's neurological symptoms began about 3 months after her initial diagnosis, potentially making it the first known case of COVID-19 associated CVT with symptom onset past 21 days. Anticoagulation is the mainstay treatment for CVT, and duration depends on the presence of provoking factor. CONCLUSIONS: In patients with new neurologic symptoms and recent diagnosis of COVID-19, CVT should be considered in the differential diagnosis as it can initially present in a subtle manner. Early recognition could improve patient morbidity and mortality. Reference #1: Abdalkader, M., Shaikh, S. P., Siegler, J. E., Cervantes-Arslanian, A. M., Tiu, C., Radu, R. A., Tiu, V. E., Jillella, D. v., Mansour, O. Y., Vera, V., Chamorro, Á., Blasco, J., López, A., Farooqui, M., Thau, L., Smith, A., Gutierrez, S. O., Nguyen, T. N., Jovin, T. G. (2021). Cerebral Venous Sinus Thrombosis in COVID-19 Patients: A Multicenter Study and Review of Literature. Journal of Stroke and Cerebrovascular Diseases. https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105733 Reference #2: Idiculla, P. S., Gurala, D., Palanisamy, M., Vijayakumar, R., Dhandapani, S., Nagarajan, E. (2020). Cerebral Venous Thrombosis: A Comprehensive Review. European Neurology (Vol. 83, Issue 4). https://doi.org/10.1159/000509802 Reference #3: Ostovan VR, Foroughi R, Rostami M, et al. Cerebral venous sinus thrombosis associated with COVID-19: a case series and literature review. Journal of Neurology. 2021 Oct;268(10):3549-3560. DOI: 10.1007/s00415-021-10450-8. PMID: 33616740;PMCID: PMC7897893. DI CLOSURES: No relevant relationships by Shu Xian Lee No relevant relationships by Arif Sarwari No relevant relationships by Benita Wu

Histopathological Features of Fungal Infections in Sinonasal, Oral and Orbital Sites Associated with COVID-19 Patients

Background: The COVID- 19 infections are associated with wide range of bacterial and fungal co-infections. They may be associated with various comorbidities. Definite diagnosis requires demonstration of fungi in tissue sections or in culture. Yield of organism in culture is suboptimal. Hence histopathology plays critical role in establishing the diagnosis and provide evidence of tissue invasion. Objective(s): To study the histopathological features of fungal infections in sino nasal, oral and orbital area associated with COVID-19 patients. Material(s) and Method(s): One hundred twenty cases of fungal infections involving sinonasal, oral and orbital area in laboratory confirmed COVID-19 positive patients between June-September 2021 were taken for study. Clinical data was recorded, histopathological examination was done along with periodic acid Schiff stain and culture report was obtained. Result(s): The study included 92(76.6%) males and 28(23.3%) females with age ranging from 13 to 78 years. The tissues included debridement, biopsy and excision specimen. Acute inflammation was seen in 8(6.66%) cases, chronic inflammation in 112(93.33%), granulomas in 25, thrombosis in 14, necrosis in 104, angioinvasion in 13, perineuritis in 10 and bone invasion in 18 cases. Mixed fungal infection was seen in 11cases. Conclusion(s): Histopathology remains the mainstay in diagnosis of invasive fungal infections especially when culture is negative. Copyright © 2022 Ubiquity Press. All rights reserved.

Management of frontal sinus fungal osteomyelitis in the COVID 19 era: A case series.

The aim of this study was to review different approaches and outcomes in the management of post-COVID-19 frontal sinus fungal osteomyelitis. The study included 19 patients with frontal sinus fungal osteomyelitis. The main line of treatment was surgical debridement (sequestrectomy). Approaches included combined external and endoscopic approaches (n = 15) and pure endoscopic approaches (n = 4) according to the extent and accessibility of the sequestrum. Postoperative healing was satisfactory in all patients. All patients returned to their normal daily activity within 4-6 weeks, without residual or recurrent frontal sinus infection, osteomyelitis or need for revision procedures. Within the limitation of this case series, it seems that there is no need to adopt a new therapy regimen for treatment of frontal sinus fungal osteomyelitis because the conventional and well-known treatment approach combining surgery and antifungal drugs seems to work well. However, early, and adequate debridement and sequestrectomy is crucial. Furthermore, an open approach may be required according to the extent of osteomyelitis.

Primary Presentation of Neurosarcoidosis as a Pituitary Mass with Sinonasal Involvement

Objective: Sarcoidosis is a systemic granulomatous disease identified by noncaseating granulomas that can have central nervous system (CNS) involvement but rarely presents with primary CNS involvement. Neurosarcoidosis can present with or without systemic disease and can present with mass effect, endocrinopathies, and neuropathic symptoms. We report on an unusual case of neurosarcoidosis involving a pituitary adenoma. Case report: A 45-year-old African American man presented to ophthalmology clinic with a chief complaint of worsening field of vision. Magnetic resonance imaging (MRI) showed a 3.8-cm macroadenoma containing cystic and calcified components with optic chiasm compression, near-complete opacification of the maxillary sinuses, and mucosal thickening in the frontal sinuses. Due to the COVID-19 pandemic, follow-up was delayed for 4 months while the vision loss progressed to near blindness in his right eye. After thorough evaluation, the patient was found to have near-complete right sided blindness, diffuse lymphadenopathy. After interdisciplinary discussions surgery was recommended. The patient underwent endoscopic transsphenoidal resection of the pituitary tumor and concurrent endoscopic sinus surgery. During the approach sinus mucosa was grossly inflamed. Frozen section of the sinus mucosa revealed granulomatous disease. The suprasellar mass had both soft contents which could be suctioned and fibrotic tumor with dense septations. Final pathology showed a pituitary adenoma with non-necrotizing granulomas within in the pituitary adenoma. Post-operatively, the patient was started on steroids and reported gradual improvement in his visual fields. At 3-months post-operative, MRI showed significant reduction in macroadenoma with a 1.5 cm residual tumor remaining in the sella and a decompressed optic chiasm which retracted inferiorly without any evidence of other intercranial anomalies. Literature review: Sarcoidosis occurs mostly in African Americans and Northern European women in their 3rd and 4th decades and can affect any part of the body such as the lymphatic systems, skin, lungs, and liver. Sarcoidosis is estimated to be prevalent in up to 80 per 100,000 people. CNS involvement occurs in 5 to 15% of patients with systemic sarcoidosis and can present with cranial neuropathy such as 7th nerve palsy, anticonvulsant refractory seizures, visual changes, and headaches. Pituitary involvement occurs 0.5% of patients with sarcoidosis and can present with endocrine and water metabolism dysfunction while sinonasal sarcoidosis can occur in up to 4%. Sinonasal sarcoidosis most usually presents as chronic crusting rhinitis, nasal obstruction, anosmia, and epistaxis and can show clinically as mucosal hypertrophy and external nose deformity in ~10% of these patients. Discussion and Conclusion: Symptomatic pituitary mass as the initial presentation of sarcoidosis is extremely rare. This case of primary neurosarcoidosis is unusual with its initial presentation mimicking non-functional pituitary macroadenoma with optic chiasm compression and associated vision loss. Primary presentation of neurosarcoidosis as a pituitary mass is rare but should be included in the differential diagnosis of a patient presenting with a combination of a macroadenoma, chronic sinusitis, and lymphadenopathy.

Curvularia Sinusitis in Leukemic Patients Two Case Reports and Review of the Literature

Curvularia species are dematiaceous filamentous fungi that can cause a variety of infections in both immunocompetent and immunocompromised hosts. We present 2 cases of severely immunosuppressed patients with acute invasive fungal sinusitis due to Curvularia species. Both patients had a history of hematologic malignancy with refractory disease and prolonged neutropenia. They presented with facial and sinus pain, which prompted maxillofacial computed tomography that showed acute sinusitis. Subsequently, they underwent nasal endoscopy with a biopsy that revealed a definitive diagnosis of invasive fungal sinusitis. Dematiaceous fungi are responsible for most fungal sinusitis cases, with Curvularia being one of the most common species isolated. Generally, invasive fungal rhinosinusitis may follow a relatively innocuous and nonspecific course. In addition, fungal infections may complicate chronic allergic sinusitis. Computed tomography scan is the first imaging modality of choice, and magnetic resonance imaging has a role in prognostication in acute invasive fungal rhinosinusitis. Endoscopic sinus surgery with biopsy yields a definitive diagnosis and is therapeutic. Management typically includes a combination of surgery and antifungal agents. Severe neutropenia is a significant risk factor for infection and is associated with poor outcomes. Aggressive surgical debridement, combined with antifungal therapy, should be emphasized in leukemic patients despite their prolonged neutropenia and bleeding tendency.

Repair of frontal sinus fractures: clinical and radiological long-term outcomes.

OBJECTIVE: The long-term clinical and radiological outcomes of patients surgically treated for frontal sinus fracture were assessed. METHODS: A retrospective, single-centre analysis was conducted of patients treated for frontal sinus fracture in a tertiary trauma centre between 2000 and 2017. Patients who underwent surgical repair for frontal sinus fracture followed by clinical and radiographical evaluation for at least six months were included. RESULTS: Of 338 patients admitted with frontal sinus fracture, 77 were treated surgically. Thirty patients met the inclusion criteria for long-term follow-up. The average follow-up duration was 37 months (range, 6-132 months). Reconstruction, obliteration and cranialisation of the frontal sinus fracture were performed in 14, 9 and 7 patients, respectively. Two patients with a reconstructed frontal sinus and one with an obliterated frontal sinus developed mucoceles. One patient developed forehead disfigurement following obliteration. CONCLUSION: Long-term complications of frontal sinus repair using the chosen repair techniques are rare, but patients need to be made aware of these potential complications.