Clinical Vignette 85

A middle-aged man presented with purulent nasal discharge for 3 months, associated with occasional left-sided facial pain. He had no history of fever or cough, and the only co-morbidity was that of chronic asthma, for which he had been on fluticasone and ventolin inhalers for years.

He had seen a number of doctors with no real subsequent improvement, even after short courses of oral antibiotics.

Clinical examination was unremarkable – there was no overlying maxillary tenderness. A CT of the sinuses was ultimately performed.

Questions:

  1. What is the likely underlying diagnosis?
  2. How can this diagnosis be proven, and how is it managed?

[Updated 23 September 2018]

Although the history is suggestive, it is also relatively non-specific. The diagnosis is one that can be made by a careful radiologist. The left maxillary sinus is opacified on CT, and the bones surrounding that sinus are sclerotic with irregular margins compared to the other side. The “arrow sign” also indicates small specks of high signal intensity, which are due to the aggregation of metal ions. The diagnosis is chronic fungal sinusitis, which is most often caused by various members of the aspergillus family. Both confirmation of diagnosis and treatment is done surgically – an ENT surgeon can access and remove the fungus and other debris from the affected sinus, which often has a characteristic appearance. Although invasive disease is neither suggested by the clinical history nor seen on the CT, that is also best assessed by the surgeon. Antifungal medications are usually unnecessary after surgical treatment (nor does it work very well if conservative treatment is opted for).

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