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We report a rare case of granulomatosis with polyangiitis (GPA) presenting with bilateral orbital apex syndrome (OAS). A 73-year-old woman with a history of endoscopic sinus surgery for ethmoidal sinusitis experienced a sudden decrease in visual acuity (VA) of both eyes. At the initial examination, her VA had decreased to 0.01 in the right eye and 0.03 in the left eye, and eye movement in both eyes was mildly limited in all directions. Visual field tests of both eyes showed a large central scotoma. Laboratory tests revealed an elevation of myeloperoxidase-anti-neutrophil cytoplasmic antibody. Facial computed tomography demonstrated a thickened mucosal membrane in the entire ethmoidal sinus, and the posterosuperior walls of Onodi cells filled with infiltrative lesions had thinned. Orbital magnetic resonance imaging showed severe inflammation in the orbital apex. From these clinical findings, the patient was diagnosed with GPA presenting with OAS associated with ethmoid sinusitis. Emergent endoscopic sinus surgery was performed for biopsy and debridement of the ethmoidal and sphenoid sinusitis to decompress the optic nerve. One day after endoscopic sinus surgery, the patient’s VA and visual field were improved, and steroid pulse therapy was commenced postoperatively. Four days later, VA had recovered to 1.0 in both eyes, and eye movement and visual field had were improved. Although OAS is a rare manifestation, early surgical treatment should be considered when the orbital lesion presents as risk of rapid deterioration of visual function in patients with GPA.

Background and aim of the work: Fungal rhinosinusitis (FRS) is a clinical entity characterized by the presence of fungi within sino-nasal cavities that may occur in patients with normal or defective immunity. Allergic fungal rhinosinusitis (AFRS) is a form of non-invasive FRS that affects patients with an abnormal immuno-mediated response to fungal antigens. This article describes a case of isolated fronto-ethmoidal AFRS. Methods: A 20-year old male patient presented with a history of a left nasal respiratory obstruction and allergic oculorhinitis. CT scans showed a polypoid mass in the left nasal cavity and opacification of the left ethmoid sinus, frontal recess and frontal sinus with hyperdense component. The patient underwent functional endonasal sinus surgery (FESS) with removal of nasal polyps from the left nasal cavity and of cheesy-like material and dense mucus from the left ethmoid and frontal sinus. Histological examination showed presence of fungal hyphae within the allergic mucus; a diagnosis of AFRS was made. Results: Follow up at 14 months showed no signs of recurrence. Conclusions: The AFRS case reported herein is characterized by isolated unilateral fronto-ethmoid involvement, a rare presentation. Endoscopic nasal treatment was effective with complete patient recovery. (www.actabiomedica.it)

Introduction Ostiomeatal complex variations may be affected by maxillary and ethmoid sinus pathologies. Objectives: To evaluate the presence of accessory maxillary ostium (AMO), Haller cell (HC), maxillary sinus patho­logies, and ethmoid sinusitis, using cone-beam computed tomography (CBCT). Material and methods CBCT images of 628 patients (339 males and 289 females) between 19 and 91 years (mean age, 47.5 ± 15.3 years) were retrospectively evaluated. Presence of AMO, HC, maxillary sinus pathologies, and ethmoid sinusitis was investigated. Maxillary sinus pathologies were classified. Associations of parameters with each other, and with maxillary sinus pathologies and ethmoid sinusitis were observed. Chi-square test was applied to analyze the relationships between variables and distribution of parameters. Results AMO was detected in 27%, HC in 15.3%, ethmoid sinusitis in 61.5%, and maxillary sinus pathology in 47.9% of the images. The most common maxillary sinus pathology was localized mucosal thickening, with 28.8% on the right and 25.2% on the left. Statistically significant differences were determined between AMO and maxil­lary sinus pathologies with ethmoid sinusitis (p < 0.001), and HC with maxillary sinus pathologies (p < 0.05). Maxillary sinus pathology and presence of ethmoid sinusitis were more common in males (p < 0.001). Conclusions There was a significant association among maxillary sinus pathology, AMO, HC, and ethmoid sinusitis. Significant relationship was observed between ethmoid sinusitis and all parameters, except for HC. The presence of these variations may increase the possibility of maxillary and ethmoid sinus pathologies. CBCT is a very successful imaging method in examining the anatomy of the paranasal sinus region.

Background: Subperiosteal abscesses (SPOA) are a complication of acute purulent sinusitis, and their optimal treatment regime is a controversial topic. Some otolaryngologists consider surgery to be mandatory in the treatment of subperiosteal abscesses others advocate that especially paediatric patients can be treated medically in some cases. The purpose of this study was to evaluate our current treatment guidelines for subperiosteal abscesses. Methodology: A retrospective study was undertaken from 2010 to 2016, including patients registered with the diagnosis of subperiosteal abscesses derived from acute sinusitis based on clinical diagnoses, and CTs or MRIs. All patients received treatment with IV-antibiotics and were booked for prompt surgery. The main outcome measures were CT-measurements and intraoperatively identified pus. Treatment included antibiotic choice, microbiology, and outcomes. Results: Thirty-one patients were included in the study having the diagnosis of sinusitis and SPOA. Per operatively, we found pus in the subperiosteal space in 21/31 patients and 17 of the patients with available contrast-enhanced CT scans. When patients were grouped based on radiographically confirmed abscesses or not per the preoperative MRI or CT, we found that the presumed abscess volume was 0.83 mL greater in the patients, who had an abscess confirmed during surgery. Two patients needed endoscopic re-operation. In addition, three patients had sequela at the last follow-up, two with minor subjective sequelae due to oedema most likely resolving themselves over time and one with memory and concentration difficulties due to intracranial empyema. Conclusion: Endoscopic drainage of SPOA combined with an intravenous antibiotic is a safe and effective treatment strategy when executed in trained surgical hands, which is substantiated by low recurrence and morbidity rates. Because of the relatively high incidence of contrast-enhanced CT-confirmed subperiosteal abscesses that cannot be identified intraoperatively, we suggest considering other parameters such as volume of the abscess to determine whether surgical intervention is needed.

Introduction. Rhinosinusitis polyposa consists in a chronic inflammation of the mucous membrane of the nose and paranasal sinuses, followed by recurrent growth of polyps and characterised by a high prevalence. Nasal polyps may be associated with the presence of viscous mucin; their characteristic CT signs are hyperostosis of the walls of the affected sinuses and thinning cavity walls until the bone is destroyed, this being a sign of aseptic osteomyelitis. The same sign is typical for inverted papilloma, the most common benign tumour of the nose and sinuses.Materials and methods. The present article presents a clinical observation. What makes it interesting is that a benign tumour was diagnosed against the background of bilateral rhinosinusitis polyposa. The clinical picture did not have nasal bleeding, which is typical for inverted papilloma; this was most likely due to the initial growth of the tumour. Thickening bone structures (hyperostosis) was balanced due to the pathogenetic peculiarities of the rhinosinusitis polyposa development with viscous mucin. Inverted papilloma was suspected during rhinoscopy, which revealed asymmetric growth of polyps. Final verification of the clinical diagnosis was carried out following computerised tomography of the nose and paranasal sinuses and histological examination of biopsy material.Results and discussion. This clinical case is of interest due to rhinocytogram data suggesting a viral and inflammatory etiology of the development of inverted papilloma. Therefore, the observed nucleoli of the nuclei of the columnar epithelium are characteristic of intracellular infection — in particular, viral. Remodelling of cells of the cylindrical epithelium is a sign of chronic inflammatory process.Conclusion. Thus, accurate performance of the diagnostic algorithm with histological verification of all removed material allows the identification of a neoplasm of the nasal cavity even in difficult cases, along with other diseases of the nasal cavity. Rhinocytogram data can help suggest the etiology of the intracellular type of infection in the epithelial cell and pathogenesis of inverted papilloma in a particular case.

Patient: Male, 49-year-old Final Diagnosis: Rhinosinusitis Symptoms: Cough • fatigue • headache • seizure Medication: — Clinical Procedure: — Specialty: Infectious Diseases Objective: Rare coexistence of disease or pathology Background: We present a case of invasive sinusitis with rhinocerebral infection in a patient who had mild symptoms of COVID-19 infection and did not receive any immunosuppressive therapies. Case Report: A 49-year-old man with a history of uncontrolled diabetes presented to the hospital with multiple generalized tonic clonic seizures. He had recently been diagnosed with mild COVID-19 and was treated at home with supportive care only. He was found to have cerebritis in the right frontal lobe along with right fronto-ethmoid sinusitis. He underwent extensive testing with nasal endoscopy with gram stain and culture, cryptococcal studies, 1–3-Beta-D glucan, blood cultures, fungal CSF studies, Lyme disease, HIV, Fungitell assay, and galactomannan studies, which were all negative. He was started on i.v. antibacterial therapy with cefepime, vancomycin, and metronidazole along with amphotericin B. After 2 weeks, his repeat imaging revealed progression of cerebritis along with new early abscess. Given these findings, his antibiotics were changed to meropenem and the amphotericin B dose was increased. He was recommended debridement and sinus surgery but refused. During the course of treatment, he developed acute kidney injury and was switched to Posaconazole. Unfortunately, the patient decided to leave against medical advice 6 weeks into admission. He was advised to continue Posaconazole and levofloxacin but he could only afford levofloxacin. He was then recommended long-term levofloxacin. He has since recovered, with resolution of cerebritis noted in follow-up imaging 1 year later. Conclusions: Our patient had mild COVID-19 infection and presented with secondary infective complications, which are usually associated with an immunocompromised state, despite receiving no immunosuppressives. It is imperative that all clinicians treating COVID-19 be watchful for fungal or bacterial co-infections in patients with active SARS-CoV-2 infection, even if the presenting symptoms are mild, particularly if other risk factors are present.

Mucormycosis is a life-threatening infection affecting patients with diabetes. It is an angioinvasive disease often resistant to treatment with a debilitating course and high mortality. Here, we report a case of a 45 year old woman with type 2 diabetes mellitus who presented to us with history of right-sided ptosis and facial palsy, and subsequently developed loss of vision and palatal palsy. She was in diabetic ketoacidosis. Nervous system examination revealed involvement of right second, third, fourth, sixth, seventh, ninth, and tenth cranial nerves, suggestive of Garcin syndrome. The hard palate had been eroded with formation of black eschar. Computed tomography of paranasal sinuses revealed right maxillary and ethmoid sinusitis, with spread of inflammation to infratemporal fossa and parapharynygeal neck spaces. Debridement of sinus mucosa was done, and culture of the same yielded growth of rhizopus species. Histopathological examination of the tissue showed angioinvasion and fungal hyphae suggestive of mucormycosis. She was treated with amphotericin B, posaconazole, and periodic nasal sinus debridement, but her general condition worsened after 8 weeks due to secondary sepsis and she succumbed to death.

We report the case of a patient with pneumonia caused by the new coronavirus (COVID-19 pneumonia), who contracted the novel coronavirus (SARS-CoV-2) infection on a large cruise ship, and was hospitalized due to fever and cough The fever resolved immediately after admission, however, a mild cough persisted Chest CT showed multiple ground-glass opacities in the upper and lower lobes of both lungs However, we judged that the patient was at a low risk of exacerbation of the disease as he was young, and did not administer any antiviral drugs Since the subjective symptoms improved, we repeated the SARS-CoV-2 PCR test on day 9 after the onset of the illness, but the result was still positive As the patient was observed to have sinus stenosis in the left nasal cavity at the time of collection of the nasopharyngeal swab for testing, sinus CT was performed The findings were suggestive of inflammation of the left nasal mucosa, ethmoid sinusitis, and maxillary sinusitis It took a long 41 days before we could finally confirm two consecutive negative results of the nasopharyngeal swab PCR test for the novel virus It has not yet been clarified whether the SARS-CoV2-19 virus can cause rhinitis and/or sinusitis, but from our experience of this case, we believe that SARS-CoV2-19 can colonize already infected nasal mucosa and sinuses for a prolonged period of time It is necessary to pay attention to this aspect, as it may prolong the disease duration and/or increase the risk of relapse

Patients with cystic fibrosis (CF) are at increased risk of nasal polyps. We present the case of a 17-month-old Caucasian patient with CF who presented with hypertelorism causing cycloplegic astigmatism, right-sided mucoid discharge, snoring and noisy breathing. Imaging suggested bilateral mucoceles in the ethmoid sinuses. Intraoperatively, bilateral soft tissue masses were noted, and both posterior choanae were patent. Polypectomy and bilateral mega-antrostomies were performed. Histological examination revealed inflammatory nasal polyposis typical of CF. The role of early functional endoscopic sinus surgery (FESS) in children with CF nasal polyposis remains questionable as the recurrence rate is higher, and no improvement in pulmonary function has been shown. Our case, however, clearly demonstrates the beneficial upper airway symptom relief and normalisation of facial appearance following FESS in a child with this condition.

Les sinusites aspergillaires invasives sont des infections fongiques opportunistes rares, rapidement extensives de pronostic redoutable. Elles surviennent preferentiellement sur un terrain d'immunodepression. Leur presentation clinique et radiologique est peu specifique. Le diagnostic positif est oriente par l'imagerie mais sa confirmation est anatomopathologique et/ou mycologique. Seule une prise en charge medico-chirurgicale rapide et adequate permettra un meilleur pronostic chez les patients atteints de cette infection. Patient âge de 60 ans, suivi pour un diabete de type 2, a consulte pour des douleurs retro-orbitaires gauches avec œdeme palpebral homolateral et fievre evoluant depuis 7 jours. L'examen physique a trouve un œdeme palpebral, un ptosis et une rougeur oculaire. L'endoscopie nasale a objective une muqueuse congestive et necrosee. L'examen biologique a montre des valeurs glycemiques tres elevee. La TDM du massif facial a revele une sinusite ethmoido-maxillaire gauche avec epaississement des tissus mous palpebraux gauches et une infiltration de la graisse extra-conique. Plusieurs diagnostics ont ete evoques notamment un lymphome, une tuberculose ou une neoplasie solide. L'examen mycologique a confirme la presence de filaments myceliens d'Aspergillus fumigatus. Il a eu une ethmoidectomie gauche avec excision des lesions necrotiques par voie endonasale. Le traitement medical s'est base sur l'amphotericine B et l'insulinotherapie pour equilibrer son diabete. L'examen anatomopathologique a conclut a une necrose de la muqueuse nasale avec presence de nombreux filaments myceliens. L'evolution etait favorable avec un recul de 2 ans.

L’accident vasculaire hemorragique et la meningite purulente constituent des urgences medicales chez la personne âgee. L’objectif est de rapporter un cas d’accident vasculaire hemorragique associe a une meningite purulente a Neisseria meningitides survenus chez une personne âgee. Il s’agit d’une patiente de 62 ans sans antecedent pathologique connu, a ete admise aux urgences medicales du CHU YO pour cephalees + vomissement et notion de perte brutale de connaissance. L’examen a son admission notait un syndrome infectieux, une conscience obnubilee sans deficit moteur, une raideur cervicale et une hypertension arterielle. La tomodensitometrie cerebrale avait objective une hemorragie meningee diffuse avec inondation du 4 eme ventricule responsable d’une hydrocephalie triventriculairesous jacente d’allure obstructive associee a des sinusites ethmoido-sphenoidales droites chroniques. Une ponction lombaire realisee avait montre un liquide cerebrospinal citrin dont l’analyse etait en faveur d’une meningite purulente a meningocoque. La glycemie etait elevee a 15,8 mmol/l et l’hemoglobine glyquee etait egale a 7,7%. L’evolution a ete favorable sous traitement a base de ceftriaxone et de Metformine. Devant un cas suspect de meningite chez une personne âgee, la ponction lombaire apres un TDM cerebral permet de poser le diagnostic et d’entreprendre rapidement une antibiotherapie indispensable pour la prevention des complications.

Objectives The aim of the present prospective, randomized, double-blind, and placebo-controlled investigation (approved by the Ethical Committee of Padova University Hospital [Italy]) was to assess the effect of a nasal gel containing a combination of silver sucrose octasulfate and potassium sucrose octasulfate (Silsos gel® [SG]) in wound healing after endoscopic sinus surgery (ESS) for chronic rhinosinusitis in terms of: nasal symptoms (SNOT22), endoscopic appearance of the sinonasal mucosa (Lund–Kennedy score), nasal air flow (anterior active rhinomanometry), evidence of mucosal inflammatory processes (nasal cytology and histology), and microbiological growth. Methods Thirty-four patients with chronic rhinosinusitis were randomized on a 1:1 ratio to receive after ESS either SG or placebo (contained only the excipients [carbopol and propylene glycol] in the same concentrations as in SG). Results/conclusions Judging from the present prospective investigation on patients who underwent ESS for chronic rhinosinusitis, treatment with SG seems to enable a significantly faster improvement in specific symptoms (assessed on the validated SNOT22 scale) than placebo. Patients treated with SG also had a quicker improvement in the endoscopic appearance of their nasal mucosa after ESS than patients treated with placebo. These endoscopic improvements in the SG group were also confirmed at the long-term follow-up, while the same did not apply to the placebo-treated group.

We report a 22-year-old man who presented with a 3 week history of left-sided headache, orbital pain and epiphora progressing to diplopia. He was being treated by his general practitioner with a β-blocker and simple analgesia for possible diagnosis of cluster headaches. Initial examination revealed a reduction in visual acuity and poor abduction and upward gaze. Routine blood tests were normal. CT imaging was reported as a left ethmoid sinusitis with extension into a left orbit subperiosteal abscess. No pus was obtained on frontal sinus trephine and a biopsy was taken, which proved to be an alveolar-type rhabdomyosarcoma. The patient has completed a full course of chemoradiotherapy and has responded well to the treatment. His vision is back to normal and an MRI has shown complete regression of tumour.

Chronic sinonasal inflammation is associated with tissue remodeling, such as osteitis, which may be a marker of refractory disease; however, the pathophysiology of osteitis in chronic rhinosinusitis (CRS) is insufficiently understood.Ethmoid mucosa and bone samples were obtained from 35 medically refractory CRS patients and 9 control subjects. Quantitative real-time polymerase chain reaction (RT-PCR) was performed separately on bone and mucosa for matrix metalloproteinase 2 and 9 (MMP2, MMP9) and tissue inhibitor of matrix metalloproteinase 1 (TIMP1). Osteitis was classified as mild, moderate, or severe by measuring bone thickness of the maxillary, sphenoid, and ethmoid sinuses on multiplanar computed tomography (CT). Patients were classified based on severity of osteitis and compared to controls.Nine patients demonstrated radiographic evidence of osteitis (mild = 3, moderate/severe = 6). Bone PCR revealed biologically significant upregulation of MMP9 in all patients with CRS, but the magnitude of the upregulation decreased with severity of osteitis. Mucosa PCR showed upregulation of MMP9 in moderate/severe osteitis only. No significant changes were seen in MMP2 or TIMP1 regulation.This is the first study to evaluate the role of MMP in the bone and mucosa of patients with sinonasal osteitis. The pattern of expression suggests there may be a time- and tissue-dependent role for MMP9 in the pathophysiology of osteitis. In addition, MMP9 overexpression is seen despite preoperative oral and intranasal steroid use, suggesting that if MMP9 is an important factor in the development of osteitis then steroids may not be the best treatment in prevention of osteitis.

We herein report a young patient with cerebral venous thrombosis (CVT) with clinical and neuroradiological findings of the left maxillary and anterior ethmoid sinusitis. Serial brain MRIs showed cerebral venous infarct and thrombosis in the superior sagittal sinus (SSS). MR angiography demonstrated nonvisualization of SSS and bilateral transverse sinus. According to our knowledge, CVT associated with maxillary and ethmoid sinusitis has been reported very rarely. High index of suspicion and neuroimaging studies, especially brain MRI, and conventional or MR angiography are very important for the early diagnosis of CVT.

The authors report the case of na eighteen years old patient with a clinical picture of orbital abscess caused by ethmoid sinusitis. The decision for surgical intervention results from correlation between clinical findings and from the image diagnosis. Relato de um caso de uma paciente de 18 anos com um quadro clinico de abscesso orbital causado por sinusite etmoidal. A decisão pela intervenção cirúrgica resultou da correlação entre achados clínicos e do diagnóstico dos exames de imagem.

A 23-year-old woman presented with clinical symptoms suggestive of acute dacryocystitis. She had no history of epiphora, and her lacrimal drainage system was patent on irrigation. CT findings were consistent with anterior ethmoiditis and maxillary sinusitis. Although the symptoms responded to antibiotic treatment, they recurred 2 times within the following 5 months. During the last episode, a complete obstruction of the nasolacrimal duct developed. The condition did not recur after external dacryocystorhinostomy and anterior ethmoidectomy during a follow-up of 21 months. Ethmoiditis may rarely cause a localized infection in the lacrimal sac region mimicking dacryocystitis. Recurrent infections may progress to complete obstruction of the nasolacrimal duct.

Seventy-eight patients of chronic sinusitis were subjected to functional endoscopic sinus surgery by the technique described in the previous paper. The clinical features, findings at surgery and the results of this technique are described here.

Prevalence of paranasal sinus abnormalities on MRI in a non-ENT population.Gordts F, Clement PA, Buisseret T. Free University of Brussels, ENT Department, Belgium. A prospective MRI sinus study primarily applied to a group of patients with suspected neurological intercranial pathology is carried out. Even in this non-ENT population, the prevalence of inflammatory sinusitis abnormalities on MRI is high.

This article presents a case of bilateral ethmoid sinusitis with unilateral proptosis as a presenting sign of an unsuspected prostate carcinoma. A 59-year-old Hispanic male presented to his primary care physician with nasal congestion and rhinitis. He was treated with antibiotics and antihistamine decongestants for 3 weeks without improvement. A trial of steroids resulted in brief improvement followed by a rapid onset of nasal obstruction with proptosis. A computed tomography scan revealed opacification of the ethmoid sinus with right proptosis. The presumptive diagnosis was orbital cellulitis secondary to chronic ethmoid sinusitis. Endoscopic sinusotomy and bilateral ethmoidectomies were performed. Biopsy results returned as metastatic adenocarcinoma, probably of prostate origin. Urological work-up and evaluation with biopsy confirmed the diagnosis of prostatic carcinoma. The patient was treated with chemotherapy and radiation therapy. He died 7 months later with disseminated disease.

In a prospective study, patients with the diagnosis of chronic ethmoid sinusitis were evaluated microbiologically by using biopsy specimens of the ethmoid sinus mucosa. Microbiology cultures were performed on 94 specimens from 59 patients. Staphylococcus aureus and members of the family Enterobacteriaceae were the most frequent classical pathogenic bacteria isolated. Coagulase-negative staphylococci were the most common overall isolates. Streptococcus pneumoniae and Haemophilus influenzae were infrequent isolates. No anaerobes, viruses, or Chlamydia trachomatis organisms were identified. Results of this study showed organism isolation frequencies different from those found in other studies of chronic sinusitis reported in the literature. The predominance of S. aureus and members of the family Enterobacteriaceae could have an effect on the antimicrobial therapy for chronic ethmoid sinusitis.

In neutropenic patients, lungs are involved in 50%-80% of cases of fusariosis, but imaging of pulmonary fusariosis has been previously described as indistinguishable from other invasive mould diseases. Our attempt was to identify a radiological pattern that may distinguish pulmonary fusariosis from other mould diseases. We examined the CT findings of nine neutropenic haematology patients with invasive fusariosis. As control group for comparison, we examined 14 invasive mould diseases (11 aspergillosis, 3 mucormycosis) in haematology patients with similar underlying disease and timing of CT imaging. Chest-CT in invasive fusariosis showed small airways (7/9) or peribronchial (5/9) infiltrates, less frequently macronodular consolidations (4/9) with hypodense sign, but without halo sign or occluded-vessel sign. The control group presented macronodular consolidations with occluded-vessel sign in all of the cases; the halo and the hypodense signs were observed, respectively, in 100% and 82% of aspergillosis, and in 67% and 100% of mucormycosis. Sinusitis was documented by CT in 7/7 fusariosis, 2/2 mucormycosis and 5/7 aspergillosis; maxillary and ethmoid sinuses were involved in 7/7 fusariosis, in most of the cases with hyperdense opacification (rarely observed in the controls). We concluded that no radiological findings can discriminate between different mould infections, but invasive fusariosis should be suspected if chest-CT demonstrates pulmonary infiltrates with the hypodense sign, but without the halo or the occluded-vessel signs. Suspicion is greater in the presence of hyperdense maxillary and ethmoid sinusitis.