真菌性鼻窦炎课件.pptx
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- 真菌 鼻窦炎 课件
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1、DaviD Gleinser,MDPatricia Maeso,MDthe University of texas MeDical Branch (UtMB health)DePartMent of otolarynGoloGyGranD roUnDs PresentationJanUary 30,2012introDUctionFungi are ubiquitousImmune system keeps organisms suppressedMost infections are benign,non-invasiveImmunocompromised higher risk of in
2、vasive diseaseNon-invasive vs.invasiveBasic MycoloGy20,000 1.5 million fungal speciesFew dozen species cause human infectionForms:yeast or moldYeastUnicellularReproduce asexually by buddingPseudohyphae when bud doesnt detach from yeastMoldMulticellularGrow by branching hyphaePseUDohyPhae vs.hyPhaeBa
3、sic MycoloGySporeReproductive structure produced in unfavorable conditionsWithstand many adverse conditionsFavorable environment growthInhalation of spores most common way fungi infiltrate sinuses to cause diseaseBasic MycoloGyMicroscopic Appearance of Specific FungiAspergillusSeptated hyphae with b
4、ranching at 45MucromycosisNonseptated hyphae with branching at 90asPerGillUsNote septations(yellow arrows)and 45 degree branching(red arrows)Note the 90 degree branching and lack of septationsclassification of infectionNon-invasiveSaprophytic fungal infestationSinus fungal ball(mycetoma)Allergic fun
5、gal sinusitisInvasiveAcute fulminant invasive fungal sinusitisChronic invasive fungal sinusitisGranulomatous invasive fungal sinusitissaProPhytic fUnGal infestationVisible growth of fungus on mucus crusts without invasionMinimal to no sinonasal symptomsDiagnosisEndoscopic visualization of crusts wit
6、h fungiTreatmentRemoval of crustsNasal saline irrigationsWeekly nasal endoscopy with removal of crusts until disease process resolvessinUs fUnGal Ball(MycetoMa)Sequestration of fungal elements within a sinus without invasion or granulomatous changesInhaled spores grow while evading host immune syste
7、m(no invasion)Aspergillus most common speciesMaxillary sinus most often involved(70-80%of cases)sinUs fUnGal Ball(MycetoMa)ClinicallySymptoms due to mass effect and sinus obstructionPresents similar to rhinosinusitisCongestion,facial pain,headache,rhinorrheaPhysical examinationMild to minimal mucosa
8、l inflammationPolyps in 10%of casessinUs fUnGal Ball(MycetoMa)DiagnosisCT ScanSingle sinus in 59-94%of cases(maxillary)Complete or subtotal opacification of sinusRadiodensities within the opacificationsDue to increased heavy metal contentBony sclerosis;destruction is rare(3.6-17%of cases)Biopsy=fung
9、al elementsfUnGal BallImages show thickening of bony walls(short arrows)and heterodense material within the sinus with calcifications(long arrows)sinUs fUnGal Ball(MycetoMa)TreatmentComplete surgical removal of fungal ballIrrigation of involved sinusesAntifungal therapyOnly if patient is high risk f
10、or invasive disease(very rare)Severely immunocompromisedContinued recurrence of disease despite proper medical/surgical managementConsider topical antifungal irrigation first and then systemic therapy if no improvementfUnGal BallallerGic fUnGal sinUsitisFungal colonization resulting in allergic infl
11、ammation without invasionIgE mediated response to fungal proteinSymptoms:Nasal obstruction(gradual)RhinorrheaFacial pressure/painSneezing,watery/itchy eyesPeriorbital edemaallerGic fUnGal sinUsitisDiagnostic Criteria1.Eosinophlic mucin2.Nasal polyposis3.Radiographic findings4.Immunocompetance5.Aller
12、gy to fungiallerGic fUnGal sinUsitisEosinophilic MucinPathognemonicThick,tenacious and highly viscousTan to brown or dark green in appearanceMicroscopic examinationBranching fungal hyphaeSheets of eosinophilsCharcot-Leyden crystalsBreakdown of cells by enzymes produced by eosinophilsSlender and poin
13、ted at each endPair of hexagonal pyramids joined at baseseosinoPhilic MUcinallerGic fUnGal sinUsitisRadiographic findingsCTUnilateral(78%of cases)Sinus expansionBone destruction in 20%of casesMore often in advanced or bilateral disease“Double Densities”Heterogeneity of signal increased heavy metal c
14、ontent(iron and manganese)and calcium saltsallerGic fUnGal sinUsitisArrows show double densities.Note sinus expansionallerGic fUnGal sinUsitisDouble densities(arrows).Expansion of sinus with extension of disease into the nasal cavity(star)allerGic fUnGal sinUsitisRadiographic findingsMRIVariable sig
15、nal intensity on T1(usually hyperintense)T2 hypointense central portion(low water content of mucin)with peripheral enhancement due to edemaallerGic fUnGal sinUsitisT1 MRI high signal intensity of debris T2 MRI central area of low intensity surrounded by high intense signalallerGic fUnGal sinUsitisT1
16、 MRI high signal intensity of debris T2 MRI central area of low intensity surrounded by high intense signalallerGic fUnGal sinUsitisAllergy to FungiMost patient with AFS will have allergy to fungus causing diseaseManning et alProspective studyCompared8 patients with AFS and(+)culture with Bipolaris1
17、0 controls with chronic rhinosinusitisAll 8 patients showed(+)skin testing,RAST,and ELISA to Bipolaris8 of 10 controls(-)for all testsIgE levels 1000 IU/mLallerGic fUnGal sinUsitisTreatmentSurgicalRemove all mucinProvide permanent drainage and ventilation of affected sinusesSystemic+/-topical steroi
18、dsSystemic steroids decrease rate of recurrenceCourse can range from 2-12 months-Schubert showed that longer courses had better results,but more side effects0.5mg/kg Prednisone starting dose and taper over 2-3 monthsallerGic fUnGal sinUsitisImmunotherapyDecrease recurrenceAlleviate need for steroids
19、Prospective reviewAll patients had surgery and systemic steroidsOne group got immunotherapy,the other did notConsisted of fungal and non-fungal antigens to which patients were sensitiveAfter 1 year:No requirement for systemic or topical steroids by patients in immunotherapy groupRecurrence of diseas
20、e significantly less in immunotherapy groupallerGic fUnGal sinUsitisImmunotherapyFolker et alRetrospective studyCompared 11 patients who received immunotherapy post-operatively vs.11 who did notRecurrence rates did NOT decreaseHowever:Quality of life scores and mucosal edema were much better in thos
21、e who received immunotherapyacUte fUlMinant invasive fUnGal sinUsitisPatient populationMost often compromised immune systemDM,AIDS,hematologic malignancies,organ transplant,iatrogenic(chemotherapy and steroids)Most common fungiAspergillusMucormycosisMucor,Rhizopus,AbsidiaLess common fungiCandidaBipo
22、larisFusariumacUte fUlMinant invasive fUnGal sinUsitisPathogenesisSpores inhaled fungus grows in warm,humid sinonasal cavityFungi invade neural and vascular structures with thrombosis of feeding vesselsNecrosis and loss of sensation acidic environment further fungal growthExtrasinus extension occurs
23、 via bony destruction,perineural and perivascular invasionNasal and palate mucosa destroyedFacial anesthesiaProptosisCranial nerve deficitsMental status changesacUte fUlMinant invasive fUnGal sinUsitisOther signs/symptomsFever(most common 90%of cases)Loss of sensation over face or oral cavityUlcerat
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