Case: Invasive Fungal Sinusitis
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Diabetic patient, new onset of cranial nerve neuropathies
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affecting the 3rd, 4th, and 6th cranial nerves.
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Just given those that history,
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we're going to be concerned about the cavernous sinus,
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and this was on the left side.
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Here we have the soft tissue window and the bone
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window of this patient. On the soft tissue window,
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we notice that there is this inflammatory process,
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which appears to be eroding
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the lateral aspect of the sphenoid sinus. Has a little bit
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of hyperdensity and extends into the pterygoid air cell,
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communication of the sphenoid sinus.
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On CT bone windows, we have the pterygoid cell that's
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communicating with the sphenoid sinusitis.
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But unfortunately,
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we also see erosion of this lateral border of the sphenoid
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sinus, which communicates with the cavernous sinus.
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So this is not showing hyperdense secretions like one would
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of an allergic fungal sinusitis.
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We're not seeing bony thickening of a chronic osteitis,
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we're seeing an erosive acute process and we
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worry about an invasive fungal sinusitis.
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Let's look at the accompanying MRI scan.
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On the MRI scan that was sent in from the outside,
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we see the opacification of the sphenoid
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air cell in the pterygoid region,
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but we also see dark signal-intensity tissue which is
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extending from the sphenoid sinus into the adjacent
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intracranial compartment, and from there into the cavernous
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sinus. Notice that this tissue is dark in signal intensity,
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not bright in signal intensity,
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making us even more concerned
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about the potential for a fungal sinusitis.
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This examination did not include post gadolinium-enhanced scan.
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It did include a coronal scan where we can see
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this low signal-intensity tissue in the inferior aspect of the
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cavernous sinus expanding the cavernous
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sinus on the left side.
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The patient was transferred to Johns Hopkins
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and we did a follow up study with MRI.
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This is the inpatient Johns Hopkins study.
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I'm going to set this up as a three-on-one.
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And we look at the T2-weighted images, as
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well as our post gadolinium enhanced scans
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and we'll look at a CIS image.
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So on the T2-weighted scan,
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we again see low signal intensity soft tissue at the
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orbital apex and extending to the cavernous sinus on
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the left side. On the post gadolinium enhanced scan,
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we see the asymmetric enhancement
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of the anterior border of the cavernous
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sinus, as well as at the superior orbital fissure
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and orbital apex. And on the CIS image,
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which is the highest resolution image,
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you can see that dark signal intensity, which is extending
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into the foramen rotundum, and from there extending to
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the Meckel's cave region on the left side, and then the
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enhancing soft tissue that's asymmetric on
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the left side compared to the right side.
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This was a patient who had invasive fungal sinusitis
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affecting the left cavernous sinus and irritating the
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associated cranial nerves to the extraocular muscles.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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