key: cord-0810746-i2btblce authors: Manchanda, Smita; Semalti, Kapil; Bhalla, Ashu Seith; Thakar, Alok; Sikka, Kapil; Verma, Hitesh title: Revisiting rhino-orbito-cerebral acute invasive fungal sinusitis in the era of COVID-19: pictorial review date: 2021-08-31 journal: Emerg Radiol DOI: 10.1007/s10140-021-01980-9 sha: ba8231671a90ccf79fe99665634cffbfe33b4da4 doc_id: 810746 cord_uid: i2btblce COVID-19 patients have been found to have an increased incidence of superadded fungal infections because of multiple factors such as impaired cell-mediated immunity, immunosuppressive therapy, and coexistent diabetes mellitus. Recently, there has been a significant rise in the COVID-19-associated mucormycosis and aspergillosis cases involving the sinonasal cavity and the lungs. Rhino-orbito-cerebral acute invasive fungal rhinosinusitis (AIFR) is a potentially life-threatening, invasive fungal infection. Early diagnosis followed by prompt medical management and surgical intervention is crucial for patient survival. The role of cross-sectional imaging (CT/MRI) is not only to suggest a diagnosis of invasive fungal sinusitis but also to delineate the complete extent of disease. Mapping the extent of orbital and intracranial disease has prognostic as well as management implications, as involvement of these sites marks a worse prognosis. A stepwise approach to evaluation of imaging of AIFR along with a pictorial depiction of the key imaging findings is presented. There has been a recent surge in the number of cases of COVID-19-associated mucormycosis and aspergillosis in the aftermath of the pandemic in several countries [1] . Rhino-orbito-cerebral mucormycosis (ROCM) is a form of acute, invasive fungal rhinosinusitis (AIFR) caused by zygomycetes order Mucorales. The Mucor species can be a commensal in the nasal mucosa of healthy people and in the presence of immunosuppression, germinate within the nose and paranasal sinuses and further progress to ROCM. A decrease in CD4 + T and CD8 + T cells in COVID-19 patients leads to impaired cell-mediated immunity and an increased predisposition to fungal infections [2] . In addition, there is a complex interplay of factors including overexpression of inflammatory cytokines, immunosuppressive therapy, comorbidities like diabetes mellitus, and nosocomial infection sources leading to an increased incidence of AIFR. In the non-COVID setting, AIFR has been reported to be caused by many fungal species such as Mucor, Rhizopus, Rhizomucor, and Aspergillus [3] . However, in the context of COVID-19, most studies have reported Mucor species (COVID-19-associated mucormycosis/CAM). In a recent study by El-Kholy et al. [4] , Mucor species was confirmed histopathologically in 28 patients, Aspergillus fumigatus in 11, and coinfection in 3 cases. COVID management teams should have a high index of clinical suspicion for AIFR, with all patients monitored for early warning signs and symptoms. These include nasal stuffiness; foul smell; epistaxis; black nasal discharge; nasal mucosal discolouration or eschar; locoregional pain or swelling; facial paresthesia; proptosis, ptosis, sudden loss of vision or diplopia; facial palsy; altered sensorium; paralysis; and focal seizures [5, 6] . In the presence of this symptomatology, patients need to undergo clinico-radiological evaluation in the form of nasal endoscopy and contrast enhanced CT (CECT) or contrast enhanced MRI (CEMRI). We suggest a stepwise approach in the imaging evaluation of suspected rhino-orbito-cerebral AIFR with pictorial depiction of the key imaging findings. The diagnosis of AIFR is made clinically with nasal endoscopy and histopathological examination. The role of imaging in suspected AIFR is primarily for documenting the extent of disease and follow-up. CEMRI is the imaging modality of choice for suspected intracranial and intraorbital disease extension; however, it has the disadvantage of limited availability in several health set-ups, longer acquisition times, and [7] . In several institutions, non-contrast CT (NCCT) is performed, which can show the extent of the mucosal disease (earliest finding being unilateral nasal cavity soft tissue thickening) and most of the complications, except the vascular complications. Apart from evaluation of suspected intracranial and intraorbital disease extension, MRI can also be used in follow-up imaging, and equivocal CT findings. In addition, non-contrast MRI can be used in those patients with deranged renal function tests. The suggested steps while evaluating a contrast enhanced study for suspected AIFR are as follows. The first step is to rule out other etiologies of sinonasal complaints and establish the diagnosis of AIFR. Few patients may have pre-existing chronic rhinosinusitis (CRS) or CRS with polyposis (CRSwP). These would have typical imaging appearance of mucosal thickening, retention cysts, and polyposis ( Fig. 1a and b) along with thickening of the bony walls. Chronic rhinosinusitis/chronic fungal colonization would not have extrasinus soft tissue or bony destruction. Similarly, patients may have other forms of chronic fungal disease such as mycetoma or allergic fungal sinusitis [8] . Mycetoma is a mass like, noninvasive lesion composed of fungal hyphae (Aspergillus fumigatus) usually involving a single sinus. An expanded sinus with internal soft tissue contents (hypodense on CT with central areas of hyperdensity, possibly containing calcifications and hypointense on T2WI in MRI) with peripheral mucosal enhancement are the imaging characteristics of mycetoma ( Fig. 1c and d) . AIFR, on the other hand, is characterized by sinonasal mucosal thickening associated with bone erosions and extrasinus spread of the disease. It is important to recognize the early CT finding of unilateral nasal cavity soft tissue in AIFR. This extrasinus spread may also occur with intact bony walls likely through microvascular channels in the bone as seen in involvement of the posterior periantral fat [7] . The perisinus spread is characteristic and may also involve the pterygopalatine fossa and infratemporal fossa and is believed to be along the sphenopalatine artery or posterior superior nasal nerves. Intraorbital and intracranial extensions are the most dreaded complications. The next step on imaging is to completely defines the extent of the disease. This has important clinical implications as imaging provides a road-map for the degree of surgical debridement. The initial stage of disease (Table 1) commonly involves the nasal mucosa with soft tissue thickening and ulceration and bony erosion of the nasal septum. The middle turbinate (Fig. 2a) is usually involved first followed by the involvement of the inferior turbinate or ostium of the nasolacrimal duct [9] . On CECT, this would be seen as mucosal thickening, erosion of bony turbinates with lack of mucosal enhancement; or as the "black turbinate sign" on CEMRI (Fig. 2b) . This is followed by involvement of paranasal sinuses, seen as partial or complete opacification of the sinuses. The disease may spread to the adjacent palate or oral cavity with bone erosions and formation of oronasal or oroantral fistulae (Fig. 3) . The further spread of soft tissue inflammation can be to the anterior (Fig. 4) and posterior periantral space, seen as obliteration of the fat with inflammatory edema. This may be followed by necrotic abscess formation in the buccal space and bony erosions or marrow edema of the zygoma and mandible. Spread of disease (Table 1 ) from the posterior nasal cavity can be to the nasopharynx, sphenopalatine foramen, pterygopalatine fossa, and infratemporal fossa (Fig. 5) [7, 10] . Early involvement of the orbit (Table 2) is characterized by inflammation of the nasolacrimal duct and sac (Fig. 6 ). Thickening of the medial rectus is also an early sign and maybe followed by enlargement of rest of the extraocular muscles [9, 10] . Retrorbital fat stranding or patchy enhancement can be seen especially along the medial and inferior orbital fat. Bone erosion of the lamina papyracea and all orbital walls should be carefully looked for. The optic nerve can be stretched and thickened due to inflammatory edema (Fig. 7) . The soft tissue inflammation can spread to the orbital apex, superior orbital fissure, and inferior orbital fissure (Fig. 8) . Uveoscleral thickening or tenting of the posterior pole of the globe (guitar-pick sign) indicates severe Fat stranding is seen in medial extraconal compartment (arrow in g) and retrobulbar intraconal compartment (dashed arrow in g). There is tenting of globe posteriorly (curved arrow): "Guitar-pick sign." Right optic nerve is stretched with enhancement of optic nerve sheath of intraorbital part of optic nerve (*) inflammatory edema and/or orbital compartment syndrome (Fig. 7) [11] . Spread of disease from the orbital apex further leads to cavernous sinus invasion (Table 2) . On imaging (Fig. 9) , this can be seen as bulky cavernous sinus, internal hypoenhancement (suggestive of thrombosis), or altered signal intensity of cavernous sinus on MRI. Dilated superior ophthalmic vein is an indirect sign of cavernous sinus thrombosis [10, 11] . Intracranial complications (Fig. 10) include leptomeningitis or cerebritis and intracranial abscess (peripherally enhancing, low density lesions) formation. This is frequently seen along the basifrontal lobe (anterior skull base or cribriform plate erosion) and temporal lobes. Also, because of the angioinvasive property of the fungus, there is a tendency of arterial narrowing, arteritis, with aneurysm formation (Fig. 9) . The intracranial part of ICA, especially the cavernous portion, should be carefully evaluated for any narrowing. There may be large vessel infarction seen as areas of altered signal intensity with diffusion restriction on MRI [10] . MR angiography can document the degree of arterial involvement, which can be well depicted on the volume rendered images. AIFR is a potentially life-threatening condition and hence, timely diagnosis and treatment is essential. This includes aggressive medical management (amphotericin B in mucormycosis and voriconazole in aspergillosis), appropriate surgical debridement, and control of the comorbid conditions. Disease limited to the nasal cavity or sinuses is treated with endoscopic or combined approach. This includes turbinectomy, wide middle meatal antrostomy, ethmoidectomy, and sphenoidotomy [9] . Palatal necrosis is managed by infrastructure maxillectomy or palatectomy according to the extent of necrosis. Orbital extension is managed by varied surgical approaches including endoscopic subperiosteal abscess evacuation, orbital decompression, orbitotomy, and orbital exenteration [4] . This is usually accompanied by aggressive sinus debridement and sinus irrigation with amphotericin B [9] . Intracranial abscess may require neurosurgical intervention if systemic condition permits. Few cases develop progressive symptoms post locoregional debridement and need follow-up MRI to document residual and progressive lesions (Fig. 11 ). The diagnosis of AIFR is primarily based on nasal endoscopy and biopsy which also gives the etiological organism. Though it is difficult to definitely suggest aspergillosis or mucormycosis on imaging, there are few signs which help raise a diagnostic possibility. Both Aspergillus and Mucor commonly affect the ethmoid sinuses and are characterized by mucosal thickening. Complete opacification or air-fluid levels may also be seen Focal leptomeningeal enhancement (curved arrow) is also seen along the right frontal lobe in AIFR. Aspergillus is reported to have sino-cranial disease in the absence of orbital involvement [12] , with dural-based masses which are homogenous, hypointense on T2WI, and show moderate post contrast enhancement. Aspergillus has a tendency towards unilateral involvement (Fig. 12 ) compared to Mucor [13] . Mucor, however, has a marked tendency to cause invasive thrombosis of vessel walls and the characteristic "black turbinate sign" (non-enhancement of nasal mucosa or turbinates on CECT/CEMRI) [14] . It is also characterized by irregular enhancement with necrotic soft tissue lesions (Fig. 4) . Sinonasal AIFR is a potentially life-threatening, invasive fungal infection. Imaging plays a key role in the early diagnosis and mapping of disease extent, which are essential for appropriate treatment. Timely initiation of antifungal therapy and surgical intervention can significantly improve clinical outcomes. 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