Acute unilateral isolated ptosis as a complication of sinusitis in a post-COVID-19 patient.

A fit and well young man presented to our emergency department in the UK. On examination, he had an isolated left-sided ptosis; he had a 3-day history of frontal headache which was worse on head movement. He lacked any clinical signs of cranial, orbital, or preseptal infection, and his eye movements were normal. Ten days before presentation, he tested positive for SARS-CoV-2. Inflammatory markers were moderately raised, and CT of the head did not reveal any vascular abnormality or intracranial lesion. Imaging revealed opacification, predominantly in the left facial sinuses, keeping with sinusitis. He was discharged the same evening with oral antibiotics and made a full recovery over the next few days. He remained well at 6-month follow-up. The authors convey their findings to raise awareness of a rare complication of sinusitis and to demonstrate the utility of CT imaging for diagnosing sinusitis and ruling out severe pathology.

Split-bolus, single-phase contrast enhanced CT: a one-stop shop for invasive fungal sinusitis.

Contrast-enhanced magnetic resonance imaging is considered the imaging modality of choice for invasive fungal sinusitis (IFS); however, it is not feasible to perform emergency CEMRI especially in the setting of COVID-19. The CECT protocol for evaluation of suspected IFS can be modified by using split-bolus, single-phase CT as it provides an optimal soft tissue demonstration of sinonasal disease; extrasinus spread to orbit, and intracranial involvement along with simultaneous opacification of the internal carotid artery and cavernous sinus. The extent of bone erosion can also be well delineated on the multiplanar reconstructions (MPRs) in the bone window. Further a structured reporting format can help provide optimal surgical guidance in cases of IFS.

CT Imaging Features in Acute Invasive Fungal Rhinosinusitis- Recalling the Oblivion in the COVID Era.

OBJECTIVE: Recent pandemic of COVID19 infection has witnessed a re-emergence of invasive fungal sinusitis especially of the Mucor species, which has been a rare entity in the pre covid era. Covid associated mucormycosis (CAM) is one of the dreaded and fatal complications which has surfaced up and early diagnosis is critical for management and survival .It is identified to affect both subset of patients, those with active COVID-19 infection and those who have recovered from the disease in the last 4-6 weeks. Imaging features suggestive of early invasion with supportive imaging examples and relevance of these findings in clinical decision making is presented. METHODS: This paper reviews the various imaging signs of early invasion in CAM A comprehensive checklist for clinically relevant and quick reporting is also presented. RESULTS: Emphysematous or ulcerative mucosal changes in the nasal cavity is an early imaging feature of CAM. Periantral soft tissue and soft tissue within the pterygopalatine fossa are important imaging signs to indicate extrasinus invasion. Disease within pterygopalatine fossa may lead to multidirectional spread and is an important check site. These findings are seen even in absence of bony erosions owing to the neurovascular spread of disease. Intra orbital and intracranial extensions were found to be fairly common and must be sought for. CONCLUSION: The knowledge of early subtle signs of CAM on imaging can aid in prompt diagnosis of this fatal entity in the pertinent clinical setting. Imaging signs of spread of disease and delineation of its extent as inferred from CT imaging aids in prognosis and appropriate surgical management.

COVID-19-associated acute invasive fungal sinusitis: Clinical and imaging findings.

BACKGROUND AND PURPOSE: The purpose is to provide a comprehensive report describing the clinical and imaging features of Coronavirus disease 2019 (COVID-19)-related acute invasive fungal sinusitis (AIFS) and associated comorbidities. METHODS: A retrospective study was conducted on 25 patients (12 males and 13 females, mean age of 53.9±9.1 years). All patients had positive polymerase chain reaction test for COVID-19 and histopathological proof of AIFS. Patients underwent computed tomography (CT) and magnetic resonance examinations to assess sinonasal, orbital, and cranial spread. RESULTS: The most prevalent comorbidity among the study cohort was diabetes mellitus (DM). Twenty-one patients (84%) were diagnosed in the post-COVID-19 period after hospital discharge, with a mean interval of 19.1±9.2 days. Steroid treatment was given to 19 patients (76%). Orbital manifestations were the presenting symptoms in all patients, followed by facial edema, nasal discharge, and neurological symptoms. Sinonasal involvement ranged from mucosal thickening to complete sinus opacification by a predominant isodensity on CT, low T1, and high T2 signal intensity with variable enhancement patterns. Twenty-four patients had a unilateral orbital extension, and 12 patients showed signs of intracranial extension. Bone involvement was detected in 16 patients (64%). Follow-up scans in 18 patients (72%) showed rapid progression of the disease. Eight patients (32%) died, six from neurological complications and two from severe respiratory failure. CONCLUSION: Steroids, DM, and severe COVID-19 are the major risk factors of AIFS in the post-COVID-19 era. Imaging scans in all patients revealed different sinonasal, facial, orbital features, and intracranial involvement with rapid progression of the findings on follow-up scans.

Utilizing CT soft-tissue markers as a screening tool for acute invasive fungal sinusitis.

OBJECTIVES: Acute invasive fungal sinusitis (AIFS) is a rapidly progressive disease, whose delayed identification results in poor outcomes, especially in immunocompromised individuals. A surge in of AIFS in the wake of the COVID-19 pandemic has lent additional morbidity and mortality to an already precarious clinical scenario. Early detection of AIFS in individuals who are symptomatic/ at risk can allow early therapy, enabling better patient outcomes. Our study aims to determine optimal soft-tissue markers on CT for the early detection of AIFS. METHODS: In this case-control study, 142 patients with equal distribution of subjects were chosen based on histopathological diagnosis of AIFS; and their non-contrast CT scans were retrospectively assessed to determine the diagnostic utility of specific soft-tissue markers that would enable diagnosis of AIFS. RESULTS: A total of nine markers with adequate sensitivity and specificity were identified, including pterygopalatine and sphenopalatine fossae, inferior orbital fissure and nasolacrimal duct involvement, premaxillary thickening, retro-antral and orbital stranding, and infratemporal muscle oedema. It was determined that the combined occurrence of any three out of nine markers was 91.5% sensitive and 95.9% specific for diagnosis of AIFS (p < 0.005). CONCLUSION: Early, accurate detection of AIFS in predisposed individuals is possible with identification of soft-tissue markers on NECT, enabling early intervention. ADVANCES IN KNOWLEDGE: Being the aggressive disease that it is, AIFS may be managed early if the index of suspicion is held high via CT imaging; which our diagnostic checklist aims at enabling.

Revisiting rhino-orbito-cerebral acute invasive fungal sinusitis in the era of COVID-19: pictorial review.

COVID-19 patients have been found to have an increased incidence of superadded fungal infections because of multiple factors such as impaired cell-mediated immunity, immunosuppressive therapy, and coexistent diabetes mellitus. Recently, there has been a significant rise in the COVID-19-associated mucormycosis and aspergillosis cases involving the sinonasal cavity and the lungs. Rhino-orbito-cerebral acute invasive fungal rhinosinusitis (AIFR) is a potentially life-threatening, invasive fungal infection. Early diagnosis followed by prompt medical management and surgical intervention is crucial for patient survival. The role of cross-sectional imaging (CT/MRI) is not only to suggest a diagnosis of invasive fungal sinusitis but also to delineate the complete extent of disease. Mapping the extent of orbital and intracranial disease has prognostic as well as management implications, as involvement of these sites marks a worse prognosis. A stepwise approach to evaluation of imaging of AIFR along with a pictorial depiction of the key imaging findings is presented.

Imaging spectrum of acute invasive fungal rhino-orbital-cerebral sinusitis in COVID-19 patients: A case series and a review of literature.

BACKGROUND: The incidence of devastating opportunistic coinfections in patients with COVID-19 infection, their imaging features and their morbidity and mortality consequences need to be unraveled. METHODS: This is a case series presenting the radiologic features and clinical presentation of acute invasive fungal rhino-orbital-cerebral sinusitis (AIFS) in eight hospitalized patients with confirmed COVID-19 infection. RESULTS: Our patient cohort presented with symptoms of the invasive fungal disease within 12-35 days from their initial presentation with COVID-19 infection. The cross-sectional imaging features of AIFS associated with COVID-19 infection do not differ from those reported in the literature for AIFS associated with other risk factors, yet our patients had features of aggressive late-stage forms with high morbidity and mortality rate. CONCLUSION: AIFS is a possible encounter in patients with COVID-19 patients and radiologists should be familiar with its imaging features.

Sinonasal polyposis complicated with extradural abscess and lateral rectus palsy.

Sinogenic intracranial and orbital complications are infrequent complications of chronic rhinosinusitis with nasal polyposis (CRSwNP), leading to potentially fatal intracranial and orbital sequelae. The mortality and morbidity associated with these complications remain high despite the widespread use of antibiotics. We report a patient with CRSwNP presenting with acute onset extradural empyema and sixth nerve palsy in whom the diagnosis was delayed, necessitating early surgical intervention. Our case shows that delay in management and underdiagnosis of sinusitis with nasal polyposis can lead to devastating complications. A high index of suspicion, early recognition of the clinical findings and radiological evaluation with contrast-enhanced CT of paranasal sinuses, orbit and brain are essential to rule out fatal complications associated with CRSwNP. Timely endoscopic intervention and the use of antibiotics can lead to good outcomes, even in complicated cases.

The impact of COVID-19 outbreak on the incidence of acute invasive fungal rhinosinusitis.

BACKGROUND: Acute invasive fungal rhinosinusitis (AIFRS) is aggressive morbidity affecting immunocompromised patients. Coronavirus disease 2019 (COVID-19) may allow secondary fungal disease through a propensity to cause respiratory infection by affecting the immune system leading to dysregulation and reduced numbers of T lymphocytes, CD4+T, and CD8+T cells, altering the innate immunity. The aim of this study is to evaluate the incidence of acute invasive fungal rhinosinusitis (AIFRS) in COVID-19 patients. METHODOLOGY: Data for acute invasive rhinosinusitis was obtained from the Otorhinolaryngology departments at our tertiary hospital at the period from January 2017 to December 2020. Then the risk factors of comorbid diseases and fungal types between post-COVID-19 and non-COVID-19 groups regarding the incidence of AIFRS are compared. RESULTS: Consequently, the incidence of AIFRS showed a more significant difference (P < 0.05) in post-COVID-19 patients than in non-COVID-19 especially in immunocompromised patients, diabetic, renal, and liver dysfunction patients as well as patients with risk factors of AIFRS. The most common organisms affecting patients with AIFRS are Rhizopus oryzae, Aspergillus fumigatus, and Absidia mucor. CONCLUSIONS: The incidence of AIFRS is markedly prominent in post-COVID-19 patients than in those of non-COVID-19, especially in immunocompromised, diabetic, renal, and liver dysfunction patients and patients with risk factors for rhinosinusitis.

Management of complicated pediatric rhinosinusitis in the COVID-19 era.

With the ongoing development of the COVID-19 pandemic, research continues to emerge regarding the pathophysiology, characteristics, and treatment considerations for patients with COVID-19. No reports have highlighted the specific challenges posed in the management of pediatric patients with COVID-19 who present with complicated rhinosinusitis. In this report, we discuss our preoperative, intraoperative, and postoperative multidisciplinary treatment strategy for these cases and provide two examples of complicated rhinosinusitis cases in COVID-19 patients, treated with two different approaches. Pearls, insights, and a brief review of the literature are discussed.