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DOI: 10.1148/rg.275065189
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Imaging Features of Invasive and Noninvasive Fungal Sinusitis: A Review1

Manohar Aribandi, MD, Victor A. McCoy, MD2, and Carlos Bazan, III, MD

1 From the Department of Radiology, University of Texas Health Science Center, San Antonio. Recipient of a Certificate of Merit award for an education exhibit at the 2002 RSNA Annual Meeting. Received November 9, 2006; revision requested December 11 and received January 10, 2007; accepted January 11. All authors have no financial relationships to disclose.

Figure 1A
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  		Figure 1a.  Acute invasive fungal sinusitis due to zygomycosis in a 59-year-old diabetic man with pain and swelling of the left eye and left-sided facial droop. (a) Axial T2-weighted MR image shows minimal mucosal thickening in the left sphenoid sinus. The normally expected flow void of the left carotid artery is absent (arrow). (b) Axial T2-weighted MR image obtained craniad to a shows an acute infarct involving the left temporal lobe (arrows). (c) Coronal unenhanced T1-weighted MR image shows soft-tissue thickening in the region of the left cavernous sinus (arrows) secondary to invasion of the cavernous sinus by the sphenoid sinus disease. Despite aggressive treatment with amphotericin B, the patient died 5 days later.

 

Figure 1B
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  		Figure 1b.  Acute invasive fungal sinusitis due to zygomycosis in a 59-year-old diabetic man with pain and swelling of the left eye and left-sided facial droop. (a) Axial T2-weighted MR image shows minimal mucosal thickening in the left sphenoid sinus. The normally expected flow void of the left carotid artery is absent (arrow). (b) Axial T2-weighted MR image obtained craniad to a shows an acute infarct involving the left temporal lobe (arrows). (c) Coronal unenhanced T1-weighted MR image shows soft-tissue thickening in the region of the left cavernous sinus (arrows) secondary to invasion of the cavernous sinus by the sphenoid sinus disease. Despite aggressive treatment with amphotericin B, the patient died 5 days later.

 

Figure 1C
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  		Figure 1c.  Acute invasive fungal sinusitis due to zygomycosis in a 59-year-old diabetic man with pain and swelling of the left eye and left-sided facial droop. (a) Axial T2-weighted MR image shows minimal mucosal thickening in the left sphenoid sinus. The normally expected flow void of the left carotid artery is absent (arrow). (b) Axial T2-weighted MR image obtained craniad to a shows an acute infarct involving the left temporal lobe (arrows). (c) Coronal unenhanced T1-weighted MR image shows soft-tissue thickening in the region of the left cavernous sinus (arrows) secondary to invasion of the cavernous sinus by the sphenoid sinus disease. Despite aggressive treatment with amphotericin B, the patient died 5 days later.

 

Figure 2A
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  		Figure 2a.  Acute invasive zygomycosis in a 42-year-old man. (a) Axial contrast-enhanced CT scan shows right ethmoid and sphenoid sinusitis with destruction of the lateral wall of the right sphenoid sinus (arrow). There is invasion of the right cavernous sinus with occlusion of the right internal carotid artery. (b) Proton-density–weighted MR image shows the occlusion of the right internal carotid artery more clearly, with absence of the normal flow void in the artery (arrow). (c) Conventional angiogram obtained with injection of the left internal carotid artery shows cross flow to the right carotid circulation.

 

Figure 2B
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  		Figure 2b.  Acute invasive zygomycosis in a 42-year-old man. (a) Axial contrast-enhanced CT scan shows right ethmoid and sphenoid sinusitis with destruction of the lateral wall of the right sphenoid sinus (arrow). There is invasion of the right cavernous sinus with occlusion of the right internal carotid artery. (b) Proton-density–weighted MR image shows the occlusion of the right internal carotid artery more clearly, with absence of the normal flow void in the artery (arrow). (c) Conventional angiogram obtained with injection of the left internal carotid artery shows cross flow to the right carotid circulation.

 

Figure 2C
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  		Figure 2c.  Acute invasive zygomycosis in a 42-year-old man. (a) Axial contrast-enhanced CT scan shows right ethmoid and sphenoid sinusitis with destruction of the lateral wall of the right sphenoid sinus (arrow). There is invasion of the right cavernous sinus with occlusion of the right internal carotid artery. (b) Proton-density–weighted MR image shows the occlusion of the right internal carotid artery more clearly, with absence of the normal flow void in the artery (arrow). (c) Conventional angiogram obtained with injection of the left internal carotid artery shows cross flow to the right carotid circulation.

 

Figure 3A
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  		Figure 3a.  Acute invasive fungal sinusitis in a 39-year-old woman with diabetic ketoacidosis and acute left eye pain. (a) Axial unenhanced CT scan shows sinus disease in the ethmoid, maxillary, and sphenoid sinuses. Note the left-sided facial swelling. (b) Axial contrast-enhanced CT scan shows lack of enhancement in the left cavernous sinus (arrows) secondary to thrombosis from invasive fungal sinusitis. (c) Axial CT scan obtained craniad to b shows proptosis and periorbital inflammatory soft-tissue thickening on the left side (arrow).

 

Figure 3B
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  		Figure 3b.  Acute invasive fungal sinusitis in a 39-year-old woman with diabetic ketoacidosis and acute left eye pain. (a) Axial unenhanced CT scan shows sinus disease in the ethmoid, maxillary, and sphenoid sinuses. Note the left-sided facial swelling. (b) Axial contrast-enhanced CT scan shows lack of enhancement in the left cavernous sinus (arrows) secondary to thrombosis from invasive fungal sinusitis. (c) Axial CT scan obtained craniad to b shows proptosis and periorbital inflammatory soft-tissue thickening on the left side (arrow).

 

Figure 3C
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  		Figure 3c.  Acute invasive fungal sinusitis in a 39-year-old woman with diabetic ketoacidosis and acute left eye pain. (a) Axial unenhanced CT scan shows sinus disease in the ethmoid, maxillary, and sphenoid sinuses. Note the left-sided facial swelling. (b) Axial contrast-enhanced CT scan shows lack of enhancement in the left cavernous sinus (arrows) secondary to thrombosis from invasive fungal sinusitis. (c) Axial CT scan obtained craniad to b shows proptosis and periorbital inflammatory soft-tissue thickening on the left side (arrow).

 

Figure 4A
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  		Figure 4a.  Acute invasive aspergillosis in a 37-year-old man with acquired immunodeficiency syndrome who presented with proptosis of the left eye. Axial unenhanced CT scans (a obtained craniad to b) show soft-tissue thickening in the left posterior ethmoid air cells, which is destroying the medial wall of the orbit and extending into the retro-orbital soft tissues (arrow).

 

Figure 4B
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  		Figure 4b.  Acute invasive aspergillosis in a 37-year-old man with acquired immunodeficiency syndrome who presented with proptosis of the left eye. Axial unenhanced CT scans (a obtained craniad to b) show soft-tissue thickening in the left posterior ethmoid air cells, which is destroying the medial wall of the orbit and extending into the retro-orbital soft tissues (arrow).

 

Figure 5A
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  		Figure 5a.  Acute invasive zygomycosis in a 59-year-old man. (a) Axial unenhanced CT scan shows increased attenuation in the right anterior and posterior ethmoid air cells and right sphenoid sinus with soft-tissue thickening in the orbital apex (arrow). (b) Coronal unenhanced CT scan shows destruction of the medial wall and floor of the right orbit and disease extension into the orbit (arrows). (c) Axial unenhanced CT scan obtained caudad to a shows destruction of the posterior wall of the right maxillary sinus and obliteration of the periantral fat plane immediately posterior to the sinus (arrows).

 

Figure 5B
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  		Figure 5b.  Acute invasive zygomycosis in a 59-year-old man. (a) Axial unenhanced CT scan shows increased attenuation in the right anterior and posterior ethmoid air cells and right sphenoid sinus with soft-tissue thickening in the orbital apex (arrow). (b) Coronal unenhanced CT scan shows destruction of the medial wall and floor of the right orbit and disease extension into the orbit (arrows). (c) Axial unenhanced CT scan obtained caudad to a shows destruction of the posterior wall of the right maxillary sinus and obliteration of the periantral fat plane immediately posterior to the sinus (arrows).

 

Figure 5C
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  		Figure 5c.  Acute invasive zygomycosis in a 59-year-old man. (a) Axial unenhanced CT scan shows increased attenuation in the right anterior and posterior ethmoid air cells and right sphenoid sinus with soft-tissue thickening in the orbital apex (arrow). (b) Coronal unenhanced CT scan shows destruction of the medial wall and floor of the right orbit and disease extension into the orbit (arrows). (c) Axial unenhanced CT scan obtained caudad to a shows destruction of the posterior wall of the right maxillary sinus and obliteration of the periantral fat plane immediately posterior to the sinus (arrows).

 

Figure 6A
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  		Figure 6a.  Acute invasive fungal sinusitis due to zygomycosis in a 57-year-old diabetic man. (a) Axial contrast-enhanced CT scan shows increased attenuation in the left anterior and posterior ethmoid air cells with destruction of the medial wall of the left orbit (arrow). (b) Coronal contrast-enhanced CT scan shows a subperiosteal abscess occupying the inferomedial aspect of the left orbit and displacing the medial and inferior rectus muscles laterally (arrows). Note also the destruction of the orbital floor (arrowhead) and the increased attenuation in the adjacent left maxillary sinus.

 

Figure 6B
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  		Figure 6b.  Acute invasive fungal sinusitis due to zygomycosis in a 57-year-old diabetic man. (a) Axial contrast-enhanced CT scan shows increased attenuation in the left anterior and posterior ethmoid air cells with destruction of the medial wall of the left orbit (arrow). (b) Coronal contrast-enhanced CT scan shows a subperiosteal abscess occupying the inferomedial aspect of the left orbit and displacing the medial and inferior rectus muscles laterally (arrows). Note also the destruction of the orbital floor (arrowhead) and the increased attenuation in the adjacent left maxillary sinus.

 

Figure 7A
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  		Figure 7a.  Chronic invasive fungal sinusitis due to zygomycosis in a 44-year-old man. Axial (a, b) and coronal (c, d) unenhanced CT scans show bilateral mucosal thickening in the maxillary sinuses. Bone invasion is noted in the form of mottled areas of low attenuation in the zygomatic process of the right maxillary bone; this finding is best visualized on the images obtained with bone windows (arrows in b and d). There is also invasion into the soft tissues of the right cheek (arrowheads in a and c).

 

Figure 7B
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  		Figure 7b.  Chronic invasive fungal sinusitis due to zygomycosis in a 44-year-old man. Axial (a, b) and coronal (c, d) unenhanced CT scans show bilateral mucosal thickening in the maxillary sinuses. Bone invasion is noted in the form of mottled areas of low attenuation in the zygomatic process of the right maxillary bone; this finding is best visualized on the images obtained with bone windows (arrows in b and d). There is also invasion into the soft tissues of the right cheek (arrowheads in a and c).

 

Figure 7C
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  		Figure 7c.  Chronic invasive fungal sinusitis due to zygomycosis in a 44-year-old man. Axial (a, b) and coronal (c, d) unenhanced CT scans show bilateral mucosal thickening in the maxillary sinuses. Bone invasion is noted in the form of mottled areas of low attenuation in the zygomatic process of the right maxillary bone; this finding is best visualized on the images obtained with bone windows (arrows in b and d). There is also invasion into the soft tissues of the right cheek (arrowheads in a and c).

 

Figure 7D
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  		Figure 7d.  Chronic invasive fungal sinusitis due to zygomycosis in a 44-year-old man. Axial (a, b) and coronal (c, d) unenhanced CT scans show bilateral mucosal thickening in the maxillary sinuses. Bone invasion is noted in the form of mottled areas of low attenuation in the zygomatic process of the right maxillary bone; this finding is best visualized on the images obtained with bone windows (arrows in b and d). There is also invasion into the soft tissues of the right cheek (arrowheads in a and c).

 

Figure 8A
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  		Figure 8a.  Chronic invasive fungal sinusitis due to zygomycosis in a 47-year-old woman. Axial unenhanced CT scans (a obtained caudad to b) show increased attenuation in the left maxillary sinus. Note the absence of the normal fat planes along the posterior wall of the left maxillary sinus. There is extension of infection beyond the walls of the maxillary sinus into the anterior and posterior periantral soft tissues (arrows). Corresponding images obtained with bone windows showed osseous sclerotic changes in the left maxillary sinus, findings consistent with chronic sinus inflammatory changes.

 

Figure 8B
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  		Figure 8b.  Chronic invasive fungal sinusitis due to zygomycosis in a 47-year-old woman. Axial unenhanced CT scans (a obtained caudad to b) show increased attenuation in the left maxillary sinus. Note the absence of the normal fat planes along the posterior wall of the left maxillary sinus. There is extension of infection beyond the walls of the maxillary sinus into the anterior and posterior periantral soft tissues (arrows). Corresponding images obtained with bone windows showed osseous sclerotic changes in the left maxillary sinus, findings consistent with chronic sinus inflammatory changes.

 

Figure 9A
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  		Figure 9a.  Allergic fungal sinusitis due to Bipolaris in a 22-year-old man with a long history of nasal obstruction. Axial unenhanced CT scans show expansion of and increased attenuation in the anterior ethmoid, posterior ethmoid, sphenoid, and frontal sinuses bilaterally. There is characteristic hyperattenuating material within these sinuses (black arrows). Note also the smooth thinning of the posterior wall of the left frontal sinus (white arrows in b).

 

Figure 9B
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  		Figure 9b.  Allergic fungal sinusitis due to Bipolaris in a 22-year-old man with a long history of nasal obstruction. Axial unenhanced CT scans show expansion of and increased attenuation in the anterior ethmoid, posterior ethmoid, sphenoid, and frontal sinuses bilaterally. There is characteristic hyperattenuating material within these sinuses (black arrows). Note also the smooth thinning of the posterior wall of the left frontal sinus (white arrows in b).

 

Figure 10A
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  		Figure 10a.  Allergic fungal sinusitis due to Bipolaris in a 26-year-old man. (a, b) Coronal CT scans (a obtained posterior to b) show characteristic expansile, hyperattenuating material in the sphenoid, ethmoid, and right maxillary sinuses (arrows). Extension into the nasal cavity (*) from the bilateral ethmoid sinuses and right maxillary sinus is noted. (c, d) Corresponding images obtained with bone windows show smooth erosion of the roofs of the posterior ethmoid sinuses (arrowheads in c) with intracranial extension, which is possibly limited by the dura. There is also smooth erosion of the medial wall of the right orbit (arrows in d) with intraorbital extension, which is possibly limited by the periosteum.

 

Figure 10B
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  		Figure 10b.  Allergic fungal sinusitis due to Bipolaris in a 26-year-old man. (a, b) Coronal CT scans (a obtained posterior to b) show characteristic expansile, hyperattenuating material in the sphenoid, ethmoid, and right maxillary sinuses (arrows). Extension into the nasal cavity (*) from the bilateral ethmoid sinuses and right maxillary sinus is noted. (c, d) Corresponding images obtained with bone windows show smooth erosion of the roofs of the posterior ethmoid sinuses (arrowheads in c) with intracranial extension, which is possibly limited by the dura. There is also smooth erosion of the medial wall of the right orbit (arrows in d) with intraorbital extension, which is possibly limited by the periosteum.

 

Figure 10C
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  		Figure 10c.  Allergic fungal sinusitis due to Bipolaris in a 26-year-old man. (a, b) Coronal CT scans (a obtained posterior to b) show characteristic expansile, hyperattenuating material in the sphenoid, ethmoid, and right maxillary sinuses (arrows). Extension into the nasal cavity (*) from the bilateral ethmoid sinuses and right maxillary sinus is noted. (c, d) Corresponding images obtained with bone windows show smooth erosion of the roofs of the posterior ethmoid sinuses (arrowheads in c) with intracranial extension, which is possibly limited by the dura. There is also smooth erosion of the medial wall of the right orbit (arrows in d) with intraorbital extension, which is possibly limited by the periosteum.

 

Figure 10D
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  		Figure 10d.  Allergic fungal sinusitis due to Bipolaris in a 26-year-old man. (a, b) Coronal CT scans (a obtained posterior to b) show characteristic expansile, hyperattenuating material in the sphenoid, ethmoid, and right maxillary sinuses (arrows). Extension into the nasal cavity (*) from the bilateral ethmoid sinuses and right maxillary sinus is noted. (c, d) Corresponding images obtained with bone windows show smooth erosion of the roofs of the posterior ethmoid sinuses (arrowheads in c) with intracranial extension, which is possibly limited by the dura. There is also smooth erosion of the medial wall of the right orbit (arrows in d) with intraorbital extension, which is possibly limited by the periosteum.

 

Figure 11A
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  		Figure 11a.  Allergic fungal sinusitis due to Bipolaris in a 22-year-old man with a long history of nasal obstruction (same patient as in Fig 9). (a, b) Unenhanced T1-weighted MR images show characteristic high signal intensity within the left maxillary, left posterior ethmoid, and sphenoid sinuses (arrows in a) and bilateral frontal sinuses (arrows in b). (c, d) Corresponding T2-weighted MR images show marked low signal intensity within the left maxillary, left posterior ethmoid, and sphenoid sinuses (arrows in c) and bilateral frontal sinuses (arrows in d).

 

Figure 11B
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  		Figure 11b.  Allergic fungal sinusitis due to Bipolaris in a 22-year-old man with a long history of nasal obstruction (same patient as in Fig 9). (a, b) Unenhanced T1-weighted MR images show characteristic high signal intensity within the left maxillary, left posterior ethmoid, and sphenoid sinuses (arrows in a) and bilateral frontal sinuses (arrows in b). (c, d) Corresponding T2-weighted MR images show marked low signal intensity within the left maxillary, left posterior ethmoid, and sphenoid sinuses (arrows in c) and bilateral frontal sinuses (arrows in d).

 

Figure 11C
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  		Figure 11c.  Allergic fungal sinusitis due to Bipolaris in a 22-year-old man with a long history of nasal obstruction (same patient as in Fig 9). (a, b) Unenhanced T1-weighted MR images show characteristic high signal intensity within the left maxillary, left posterior ethmoid, and sphenoid sinuses (arrows in a) and bilateral frontal sinuses (arrows in b). (c, d) Corresponding T2-weighted MR images show marked low signal intensity within the left maxillary, left posterior ethmoid, and sphenoid sinuses (arrows in c) and bilateral frontal sinuses (arrows in d).

 

Figure 11D
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  		Figure 11d.  Allergic fungal sinusitis due to Bipolaris in a 22-year-old man with a long history of nasal obstruction (same patient as in Fig 9). (a, b) Unenhanced T1-weighted MR images show characteristic high signal intensity within the left maxillary, left posterior ethmoid, and sphenoid sinuses (arrows in a) and bilateral frontal sinuses (arrows in b). (c, d) Corresponding T2-weighted MR images show marked low signal intensity within the left maxillary, left posterior ethmoid, and sphenoid sinuses (arrows in c) and bilateral frontal sinuses (arrows in d).

 

Figure 12A
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  		Figure 12a.  Allergic fungal sinusitis due to Bipolaris in a 26-year-old man (same patient as in Fig 10). (a, b) T2-weighted MR images (a obtained caudad to b) show marked low signal intensity within the hyperintense ethmoid and sphenoid sinuses (arrows), an appearance that mimics normally aerated sinuses. (c, d) Corresponding contrast-enhanced T1-weighted MR images show expansile hypointense to isointense material within the centers of these sinuses (arrows) with enhancing mucosa noted peripherally. (e, f) Unenhanced T1-weighted MR images (e obtained anterior to f) show a characteristic hyperintense collection within the right maxillary sinus (*).

 

Figure 12B
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  		Figure 12b.  Allergic fungal sinusitis due to Bipolaris in a 26-year-old man (same patient as in Fig 10). (a, b) T2-weighted MR images (a obtained caudad to b) show marked low signal intensity within the hyperintense ethmoid and sphenoid sinuses (arrows), an appearance that mimics normally aerated sinuses. (c, d) Corresponding contrast-enhanced T1-weighted MR images show expansile hypointense to isointense material within the centers of these sinuses (arrows) with enhancing mucosa noted peripherally. (e, f) Unenhanced T1-weighted MR images (e obtained anterior to f) show a characteristic hyperintense collection within the right maxillary sinus (*).

 

Figure 12C
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  		Figure 12c.  Allergic fungal sinusitis due to Bipolaris in a 26-year-old man (same patient as in Fig 10). (a, b) T2-weighted MR images (a obtained caudad to b) show marked low signal intensity within the hyperintense ethmoid and sphenoid sinuses (arrows), an appearance that mimics normally aerated sinuses. (c, d) Corresponding contrast-enhanced T1-weighted MR images show expansile hypointense to isointense material within the centers of these sinuses (arrows) with enhancing mucosa noted peripherally. (e, f) Unenhanced T1-weighted MR images (e obtained anterior to f) show a characteristic hyperintense collection within the right maxillary sinus (*).

 

Figure 12D
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  		Figure 12d.  Allergic fungal sinusitis due to Bipolaris in a 26-year-old man (same patient as in Fig 10). (a, b) T2-weighted MR images (a obtained caudad to b) show marked low signal intensity within the hyperintense ethmoid and sphenoid sinuses (arrows), an appearance that mimics normally aerated sinuses. (c, d) Corresponding contrast-enhanced T1-weighted MR images show expansile hypointense to isointense material within the centers of these sinuses (arrows) with enhancing mucosa noted peripherally. (e, f) Unenhanced T1-weighted MR images (e obtained anterior to f) show a characteristic hyperintense collection within the right maxillary sinus (*).

 

Figure 12E
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  		Figure 12e.  Allergic fungal sinusitis due to Bipolaris in a 26-year-old man (same patient as in Fig 10). (a, b) T2-weighted MR images (a obtained caudad to b) show marked low signal intensity within the hyperintense ethmoid and sphenoid sinuses (arrows), an appearance that mimics normally aerated sinuses. (c, d) Corresponding contrast-enhanced T1-weighted MR images show expansile hypointense to isointense material within the centers of these sinuses (arrows) with enhancing mucosa noted peripherally. (e, f) Unenhanced T1-weighted MR images (e obtained anterior to f) show a characteristic hyperintense collection within the right maxillary sinus (*).

 

Figure 12F
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  		Figure 12f.  Allergic fungal sinusitis due to Bipolaris in a 26-year-old man (same patient as in Fig 10). (a, b) T2-weighted MR images (a obtained caudad to b) show marked low signal intensity within the hyperintense ethmoid and sphenoid sinuses (arrows), an appearance that mimics normally aerated sinuses. (c, d) Corresponding contrast-enhanced T1-weighted MR images show expansile hypointense to isointense material within the centers of these sinuses (arrows) with enhancing mucosa noted peripherally. (e, f) Unenhanced T1-weighted MR images (e obtained anterior to f) show a characteristic hyperintense collection within the right maxillary sinus (*).

 

Figure 13
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  		Figure 13.  Mucor fungus ball in a 49-year-old woman with chronic sinus pressure and halitosis. Unenhanced CT scan shows isoattenuating to hyperattenuating material filling the right maxillary sinus with central calcific areas of increased attenuation (long arrow). Note the circumferential thickening of the osseous walls of the sinus (short arrows), a finding consistent with a chronic inflammatory process.

 

Figure 14
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  		Figure 14.  Aspergillus fungus ball in a 60-year-old woman with mixed connective tissue disorder and a history of cryoglobulinemia and Sjögren syndrome. Axial unenhanced CT scan shows the typical hyperattenuating fungus ball with calcific foci in the left maxillary sinus (long arrow). Note the sclerotic thickening of the osseous walls of the sinus (short arrows) from chronic sinus inflammation.

 




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