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1Pharm D Interns, Ezhuthachan College of Pharmaceutical Sciences, Marayamuttom Neyyattinkara, Thiruvananthapuram.
2Assistant Professor, Department of Pharmacy Practice, Ezhuthachan College of Pharmaceutical Sciences, Marayamuttom, Neyyattinkara, Thiruvananthapuram.
3HOD/Principal, Department of Pharmacy Practice, Ezhuthachan College of Pharmaceutical Sciences, Marayamuttom, Neyyattinkara, Thiruvananthapuram
The sphenoid sinus, ensconced in the depths of the central cranial base and contiguous with pivotal neurovascular corridors, represents an exceptionally infrequent yet perilous locus for mycotic colonization. Owing to its concealed anatomic recess, sphenoidal mycosis frequently mimics innocuous cephalalgic syndromes or insidious optic neuropathies, thereby obfuscating timely recognition. A 36 years old female manifested with a cephalalgic affliction refractory to conventional NSAID therapy, persisting insidiously over the preceding month. Serving as a pivotal investigative modality, MRI unveils an expansile mycotic focus within the left sphenoid recess, manifesting intrinsic T1 hyperintensity and a central T2 signal void, indicative of paramagnetic fungal concretions. The lesion’s non-enhancing core, girdled by a tenuous rim of enhancement, intimates chronic granulomatous evolution. Subtle anterior sphenoidal dehiscence with posterior ethmoidal encroachment is discerned, yet the cranial base integrity endures. Contralateral sinusoidal mucosa displays moderate reactive hypertrophy, while cerebral and cavernous architectures remain pristine. The overall radiologic gestalt coheres with chronic sphenoidal fungal sinusitis. The deviation was surgically remediated using minimally invasive Functional Endoscopic Sinus Surgery(FESS).Post FESS endoscopic evaluation revealed no discernible pathological abnormalities. This case underscores the value of early vigilance and MRI in refractory cephalalgia to identify fungal sinusitis via its characteristic imaging. Timely FESS eradicated the fungal nidus, restored sinus patency, and prevented neurovascular and catastrophic complications, highlighting the need for diagnostic acuity in occult sphenoidal pathology.
Fungal infections of the paranasal sinuses constitute a heterogeneous group of disorders ranging from indolent colonization to rapidly progressive, life-threatening disease. Among these, isolated sphenoid sinus fungal infection represents one of the rarest clinical entities, owing to the deep anatomical location and relatively poor ventilation of the sphenoid sinus. Its proximity to critical neurovascular structures including the optic nerve, cavernous sinus, internal carotid artery, and pituitary gland renders even limited disease potentially catastrophic. The nonspecific nature of symptoms often leads to delayed diagnosis, underscoring the importance of heightened clinical awareness. [1] Sphenoid sinus fungal infections are broadly classified into non-invasive forms (fungal ball and allergic fungal rhinosinusitis) and invasive forms (acute invasive, chronic invasive, and granulomatous fungal sinusitis). The most frequently implicated organisms include Aspergillus species and members of the order Mucorales, with geographic and host related variations influencing pathogen prevalence. Infection typically arises from inhalation of airborne fungal spores, followed by colonization or invasion of the sphenoid sinus mucosa, particularly in the setting of impaired host defense or altered sinus drainage. [2] Several predisposing risk factors have been identified, most notably uncontrolled diabetes mellitus, prolonged corticosteroid therapy, hematological malignancies, solid organ transplantation, and other causes of immunosuppression. However, isolated sphenoid sinus fungal infections have also been reported in immunocompetent individuals, suggesting that local anatomical factors, mucociliary dysfunction, and sinus ostial obstruction may play contributory roles. Environmental exposure, advanced age, and prior sinonasal disease further increase susceptibility. [3] The clinical presentation is often subtle and misleading. Patients commonly report persistent or retro-orbital headache, vertex pain, facial discomfort, or visual disturbances, while classic nasal symptoms such as discharge or obstruction may be absent. Cranial nerve palsies, diplopia, and decreased visual acuity are particularly concerning manifestations and usually indicate advanced disease or invasion of adjacent structures. This atypical symptom profile frequently results in misdiagnosis or delayed intervention. [4] If left untreated, sphenoid sinus fungal infection may lead to serious complications, including cavernous sinus thrombosis, optic neuritis, internal carotid artery involvement, pituitary dysfunction, and intracranial extension causing meningitis or brain abscess. Mortality remains significant in invasive forms, especially among immunocompromised patients, highlighting the need for prompt recognition and aggressive management. [5] Diagnosis relies on a combination of high-resolution imaging and microbiological confirmation. Computed tomography typically demonstrates hyperdense sinus contents, bony erosion, or sclerosis, while magnetic resonance imaging is superior for assessing soft-tissue extension and neurovascular involvement. Definitive diagnosis is established through endoscopic biopsy with histopathological examination and fungal culture. [6] Management involves early surgical debridement via endoscopic sphenoidotomy combined with targeted systemic antifungal therapy, such as amphotericin B or azole agents, depending on the fungal species and disease severity. Adjunctive measures include optimization of glycemic control, correction of immunosuppressive states, and supportive lifestyle modifications aimed at reducing recurrence risk. [7] Functional Endoscopic Sinus Surgery (FESS) is a refined, minimally invasive otorhinolaryngological procedure designed to restore physiological sinus ventilation and mucociliary clearance by addressing obstructive sinonasal pathology. It employs high definition nasal endoscopes to access the osteomeatal complex through the natural nasal corridors, eliminating diseased mucosa, polyps, or inspissated secretions without external incisions. [8] Functional Endoscopic Sinus Surgery (FESS) is performed under local or general anesthesia with meticulous preoperative nasal decongestion to enhance endoscopic visibility. A rigid nasal endoscope is introduced through the nostril, allowing panoramic visualization of the nasal cavity and osteomeatal complex. Sequential surgical steps include uncinectomy, enlargement of the natural maxillary ostium, and targeted clearance of diseased ethmoidal air cells while conserving healthy mucosa. Advanced instruments such as microdebriders or powered shavers may be employed for precise tissue excision. The procedure concludes with hemostasis and, in selected cases, placement of absorbable nasal packing to maintain postoperative patency and reduce synechiae formation. [9] Here we report a case of sphenoid sinus fungal infection, which was confirmed by the symptoms and diagnosed through MRI scan of brain, MR venography and it was surgically remediated usng FESS procedure.
Case Presentation
A 36 years old female was presented with complaints of headache it was not relieved with NSAIDs. She has no past medical and medication history. The patient was conscious, oriented, chest clear and heart sounds were normal and GIT was soft and non-tender. During admission the patient had an pulse rate of 72 beats/minute, respiratory rate of 20 breaths/minute, peripheral capillary oxygen saturation was 98% and the blood pressure was 140/90 mmHg. The patient’s laboratory investigation reports showed an elevation in WBC count, ESR, Total protein and Presence of pus cells and epithelial cells in the urine and declined parameters were lymphocytes. The diagnosis was done through MRI brain and MR venography.
Figure 1: MRI Brain
Figure 2: MR Venography
The MRI scan of brain showed the left sphenoid sinus is expanded and filled with material having signal void in T2WI FLAIR, is mildly hyper intense in T1WI. CEMR does not show any enhancement in the core. Mild thick rim enhancement noted. The anterior wall of the sphenoid sinus appears eroded with lesion bulging into the posterior ethmoid cells. The other walls are intact. The cranial floor fossa intact. The right sphenoid sinus is smaller with moderate mucosal thickening having moderate enhancement. Moderate mucosal thickening in the ethmoid sinuses with moderate enhancement in CEMR. Mild mucosal thickening in the frontal and maxillary sinuses and no fluid level.MR imaging revealed no significant abnormality in the brain parenchyma. Normal parenchymal enhancement. No abnormally enhancing areas or any focal or vascular lesions become evident after contrast media administration.MR venography showed normal morphology of the cortical venous system. CEMR showed normal contrast opacification in the cranial venous sinus. The cavernous sinus show normal contrast opacification. chronic fungal sinusitis in the sphenoid sinus. The patient condition was managed with INJ. PARACETAMOL 1gm IV TDS, INJ. TRAMADOL 50mg IV Q6H, INJ. DEXAMETHASONE 1amp IV BD, TAB. GABAPENTIN 100mg P/O TDS, INJ. KETOROLAC 1amp IV BD, 50mg IV Q6H to relieve pan related to headache, INFUSON MANNTOL 100ml IV TDS to treat intra cranial and intra orbital pressure, INJ.PANTOPRAZOLE 40mg IV BD to prevent other using drugs related gastric irritation, TAB. ALPRAZOLAM 0. 25 mg P/O HS to treat anxiety related to disease condition, NEB. LEVOSALBUTAMOL P/N TDS to treat sinus infection related breathing difficulty and cough, There is only colonization of fungus in the sphenoid sinus no invasion so no antifungals are included in the treatment only antibiotics was given so INJ. CEFTRIAXONE 1gm IV TDS to treat infection.
FESS surgical procedure was performed under general anesthesia and was seen through the endoscope showed that the sphenoid sinus opening was blocked with polypoid mucosa indicates that the natural ostium of the sphenoid sinus was obstructed by edematous, inflamed mucosal tissue that has polyp like appearance clinically suggests chronic sphenoid sinusitis associated with fungal ball and the obstruction creates a hypoxic, stagnant environment ideal for fungal colonization. Through this procedure the obstruction due to polyp was removed in the sinuses and restored drainage. Fungal ball in the sphenoid sinus
Figure 3: Endoscopic images obtained during FESS procedure
TAB. ISIBRO D ( TRYPSIN, BROMELAIN, RUTOSIDE, DICLOFENAC- 48mg, 90mg, 100mg, 50mg P/O BD) to treat inflammation and helps to resolve post-operative pain, edema and promotes tissue healing, TAB. BETAHISTINE DIHYDROCHLORIDE 16mg P/O BD to prevent positional vertigo during postoperative period, TAB. HATRIC 3 (PARACETAMOL, PHENYLEPHRINE, DIPHENHYDRAMINE, CAFFEINE- 500mg, 5mg, 25mg, 30mgP/O TDS) to treat postoperative pain, reduces edema at surgical site, improves sinus ventilation, post nasal drip, minimize post-operative congestion and oozing, reduce nasal irritation, caffeine counter balancing diphenhydramine induced somnolence, TAB. ZINCOVIT (MULTIVITAMIN 1 tab P/O OD as supportive therapy for providing sufficient nutrients and vitamins to the body. XYLOMETAZOLNE NASAL SPRAY P/N 2 drops TDS to provide short term symptomatic benefit to optimize post-operative healing, post nasal drip, minimize post-operative congestion and oozing and reduce nasal irritation, NASOCLEAR NASAL WASH (SODIUM BICARBONATE, SODIUM CHLORIDE P/N TDS) for cleansing and irrigation of the nasal cavity after post-operative period and CAP. SOMPRAZ D (ESOMEPRAZOLE, DOMPERIDONE 40mg, 20mg P/O OD BD to prevent other using drugs related gastric irritation.
DISCUSSION
Sphenoid sinus fungal infections are rare and often present with nonspecific symptoms making diagnosis challenging and frequently delayed. The case reported by Sivakumar G et al[10], persistent headache was the predominant presenting symptom, similar to our patient who presented with refractory cephalalgia unresponsive to NSAIDs. Both cases highlight how isolated sphenoid involvement may initially masquerade as a primary headache disorder, delaying otorhinolaryngological evaluation. However, unlike their case where diagnosis was delayed due to nonspecific findings, early MRI in our patient facilitated timely detection before complications developed. In the case study by Pagella F et al[11], patients with sphenoid sinus fungus ball frequently presented with isolated headache and minimal nasal symptoms, closely paralleling our clinical presentation. Radiologically, hyperdense sinus contents on CT were characteristic in their report, whereas in our case, MRI demonstrated T1 hyperintensity and T2 signal void consistent with paramagnetic fungal concretions. Both cases underscore the diagnostic value of imaging, though our report emphasizes MRI as a pivotal modality in early detection. The case described by Klossek JM et al[12], involved invasive aspergillosis requiring aggressive management. In contrast, our patient exhibited a non-invasive fungal ball without evidence of cavernous sinus or intracranial extension. This distinction significantly influenced therapeutic decisions, as invasive disease necessitates systemic antifungal therapy in addition to surgical debridement, whereas our case was successfully managed with Functional Endoscopic Sinus Surgery (FESS) alone.A more severe presentation was documented by Chen YL et al [13], where isolated sphenoid sinus aspergillosis presented with visual disturbances secondary to optic nerve compression. Unlike that case, our patient did not develop neuro-ophthalmic deficits, likely due to earlier radiological suspicion and intervention. This comparison highlights the importance of prompt diagnosis to prevent irreversible complications such as optic neuropathy or cavernous sinus thrombosis. Finally, Dufour X et al [14], described the epidemiological and clinical features of paranasal sinus fungus balls, noted that most cases occur in immunocompetent individuals and are effectively treated with surgical removal alone. Our patient similarly had no underlying immunocompromised state and demonstrated complete postoperative recovery without antifungal therapy, reinforcing the concept that non-invasive fungal balls of the sphenoid sinus carry an excellent prognosis when diagnosed early and managed surgically.
Clinical Significance
Isolated sphenoid sinus fungal infection is a rare but clinically significant entity due to its deep anatomical location and close proximity to critical neurovascular structures, including the optic nerve, cavernous sinus, and internal carotid artery. The nonspecific presentation, often dominated by refractory headache with minimal nasal symptoms, contributes to delayed diagnosis and increases the risk of serious complications such as visual loss, cavernous sinus thrombosis, and intracranial spread. This case highlights the importance of maintaining a high index of clinical suspicion and utilizing appropriate imaging modalities, particularly MRI and CT, to enable early diagnosis and timely surgical intervention, thereby preventing potentially life-threatening sequelae.
Therapeutic Challenges
The management of sphenoid sinus fungal infection poses several therapeutic challenges, primarily in differentiating invasive from non-invasive disease, which directly influences treatment decisions. Radiological findings may be suggestive but are not always definitive, necessitating intraoperative and histopathological confirmation. Surgical access to the sphenoid sinus is technically demanding due to its deep location and anatomical variability, increasing the risk of perioperative complications. Additionally, the role of systemic antifungal therapy remains controversial in non-invasive fungal balls, requiring careful clinical judgment to avoid unnecessary drug exposure while ensuring complete disease clearance through meticulous endoscopic surgical management.
CONCLUSION
This case reinforces that isolated sphenoid sinus fungal infection, a rare condition should be considered in patients presenting with persistent, unexplained headaches unresponsive to conventional therapy. Early radiological evaluation followed by endoscopic surgical intervention remains the cornerstone of management, particularly in non-invasive disease, where surgery alone is often curative. Prompt diagnosis and appropriate treatment result in excellent clinical outcomes and prevent serious complications, underscoring the need for multidisciplinary collaboration and heightened awareness among clinicians in managing atypical sino nasal presentations.
REFERENCES
Ardra S. A., Nandana R. S., Grace N. Raju, Shaiju S. Dharan, Deep Seated Fungal Infection of the Sphenoid Sinus- A Hidden Threat in the Skull Base: A Rare Clinical Encounter, Int. J. Med. Pharm. Sci., 2026, 2 (5), 623-628. https://doi.org/10.5281/zenodo.20371191
10.5281/zenodo.20371191