Research Article, J Otol Rhinol Vol: 9 Issue: 7
The Association of Nasal Septal Deviation with Solitary Sphenoidal Fungus Ball: Retrospective Analysis of 43 Patients
*Corresponding Author : Nyall R London Jr
Department of Otolaryngology and Head and Neck Surgery, Johns Hopkins School of Medicine, 601 N. Caroline Street, 6thfloor, Baltimore, Maryland, USA
Received: April 23, 2020 Accepted: May 11, 2020 Published: May 18, 2020
Citation: Lifeng Li, Demin Han, Shuling Li, Nyall R. London Jr. (2020) The Association of Nasal Septal Deviation with Solitary Sphenoidal Fungus Ball: Retrospective Analysis of 43 Patients. J Otol Rhinol 2020 9:3. doi: 10.3752/jor.9(3).384
Objective: A Solitary Sphenoid Fungus Ball (SSFB) is an uncommon unilateral collection of non-invasive fungal hyphae in the sphenoid sinus. The association and potential impact of nasal septal deviation (NSD) on the pathogenesis of SSFB has not been fully assessed. The purposes of this study were to investigate whether NSD is associated with SSFB, and to assess the alterations to adjacent structures caused by SSFB. Methods: Forty-three patients with SSFB were enrolled as the study group. Another 43 age and sex matched patients that underwent trans-sphenoidal resection of a pituitary tumor were enrolled as the control group. The incidence of NSD, and alterations to adjacent bony structures were compared between these two groups. Analysis of the relationship between the direction and severity of NSD with the ipsilateral occurrence of fungus ball in the sphenoid sinus was also performed. Results: The incidence of NSD in patients with SSFB (86.05%) was statistically higher than that in control group (39.53%) (p<0.001). Neither the direction of NSD (p=0.861) nor the severity of NSD (p=0.442) would impact the ipsilateral occurrence of the SSFB. An expanded sphenoid ostia, punctate calcifications, and bony wall sclerosis were the main characteristics on CT imaging. Central signal deficiency was a typical characteristic on T2WI MRI. Conclusion: NSD was common in patients with SSFB. However, no statistically significant difference was detected between the direction and severity of NSDon the ipsilateral occurrence of the sphenoidalfungal sinusitis.
Keywords: Sphenoid sinus; Fungus ball; Nasal septal deviation; Sclerosis; Bony deficiency
A fungus ball is a collection of non-invasive fungal hyphae in the sinonasal cavity. Presenting symptoms of unilateral or solitary fungus balls are non-specific . The maxillary sinus is the most common site for occurrence of a solitary fungus ball followed by the sphenoid sinus . Both CT and MRI images can be used to aid in diagnosis [3-5], and surgical extirpation is often necessary for definitive treatment .
Aspergillusfumigatus has been reported to be the most common pathogen for development of fungal balls in the paranasal sinuses [7,8]. The pathogenesis of a fungal ball in the paranasal sinus is not fully understood and may be correlated with decreased aeration of the sinuses cavity. It was considered that ostial closure may create an anaerobic environment, which is favorable for growth of aspergillus or formation of a fungal ball .
The occurrence of maxillary fungal sinusitis was considered to be correlated with nasal septal deviation . In another previous study, however, the role of nasal septal deviation in the pathogenesis of sinusitis formation from an aerodynamics perspective has been investigated, and no significant correlation was identified between the nasal septal deviation and the chronic sinusitis . The ostia of the sphenoid sinus were aerated through the sphenoethmoidal recess; and as such, appropriate aeration of the sphenoid sinus may be impacted by the nasal septal deviation. However, whether the formation of solitary sphenoidal fungal ball (SSFB) is associated with nasal septal deviation is not sufficiently explored .
In addition to the accumulation of fungus in the sphenoid sinus, a SSFB may also impact adjacent structures such as the lateral wall of the sphenoid sinus incorporating the optic nerve canal and internal carotid artery canal , and the superior, inferior sphenoid sinus walls, and the sphenoid septum respectively. However, the association of nasal septal deviation with the local alterations to adjacent bony structures caused by sphenoidal fungal ball have not been fully assessed, and investigation of the impact of sphenoidal fungal sinusitis on adjacent bony structures may be beneficial for better appreciation of the consequent alterations caused by SSFB.
The purpose of this study was to investigate whether the nasal septal deviation is associated with the development of SSFB. Secondly, the alterations to adjacent structures caused by SSFB and the potential relationship with nasal septal deviation was evaluated.
Materials and Methods
Forty-three patients with SSFB which was ascertained with pathology after nasal surgery in a single center (Beijing Tongren Hospital) between January 1, 2014 and Dec 31, 2016 were retrospectively reviewed and enrolled as the study group. Another 43 age and sex-matched patients who underwent trans-sphenoidal resection of pituitary tumor during this timeframe were enrolled as the control group. Patients with allergic fungal rhinosinusitis and invasive fungal sinusitis (ascertained by pathologic diagnosis) were excluded from this study . Informed consent was obtained from these subjects and the study protocol was approved by the ethics Committee of Beijing Tongren Hospital.
In addition to nasal septal deviation, other structural abnormalities such as concha bullosa, paradoxical middle turbinate and inferior turbinate hypertrophy, and the presence of an Onodi cell were also compared between the study and control groups. Moreover, the alterations to adjacent structures such as the bony dehiscence of optic nerve canal and carotid artery canal, bony hyperplasia, and the expansion of natural sphenoidalostia were also compared between the study and the control groups.
The deviated angle was measured on CT scans in Mimics 13.1 (Materialise, Leuven, Belgium). It is the angle between a line drawn from the superior insertion of the septum at the crista galli to the inferior insertion of the septum to the maxillary crest, and another line from the superior insertion of the septum at the crista galli to the apex of the septal deviation. The anterior deviation in a “ S ” type or complicated type was used for measurement of the deviation angle. We defined the severity of nasal septal deviation according to the abovementioned angle: 0o to 5o was defined as mild deviation, 5o to 10o as moderate deviation, and more than 10o as severe deviation respectively .
Comparisons of the occurrence of structural abnormalities and the alterations to adjacent structures between the study and control groups were performed using t-tests. The relationship between the direction of nasal septal deviation with the ipsilateral occurrence of SSFB in the study group was assessed with correlation analysis. The evaluation of the varying severities of deviation on the laterality of occurrence of SSFB was performed by analysis of variance. A probability value of p<0.05 was considered to be statistically significant. Statistical analysis was performed using the Statistica 16.0 software (StatSoft, Inc., Tulsa, OK).
Patients with SSFB ranged from 31 to 90 years old and there were no children or adolescence identified. The percentage of occurrence for male patients (n=16) and female patients (n=27) was 37.2% and 62.8%, respectively. Main presenting symptoms in patients with SSFB were non-specific and included post-nasal drip (65.1%), headache (37.2%), and orbital discomfort (20.9%). There were 3 patients with concurrent diagnosis of diabetes, and no other immunocompromised diseases coexisted.
There were 15 patients (34.9%) with the SSFB located on the right side and 28 patients (65.1%) occurred in the left sphenoid sinus. There were 19 patients (44.2%) in which the SSFB occurred in the dominant sinus cavity and 24 patients (55.8%) occurred in the non-dominant sphenoid sinus cavity.
With regard to the structural abnormalities or variations, we detected that the presence of a nasal septal deviation in study group (86.05%) was statistically higher than that in control group (39.53%,p<0.001, Table 1). The other structures such as concha bullosa, paradoxical middle turbinate, inferior turbinate hypertrophy and presence of an Onodi cell, however, showed no difference between the two groups (p>0.05, Table 1). The occurrence of expansion of sphenoidalostia in the study group (76.74%) was statistically higher than that in the control group (4.65%) (p<0.001, Table 1). The bony sclerosis in study group (97.67%) was statistically higher than that in the control group (6.98%) (p<0.001, Table 1). The bony dehiscence of lateral sphenoidal wall (18.6%) in study group was statistically higher than that in control group (2.32%) (p<0.05, Table 1). By comparison with the study group (2.32%), the higher incidence of bony dehiscence of the sellar floor in the control group (34.88%) was detected (p<0.001, Table 1). The bony dehiscence of the sphenoidal septum, however, showed no difference between the two groups (p>0.05).
|Study group||Control group||p value|
|Nasal septal deviation||37(86.05%)||17(39.53%)||<0.001|
|Paradoxical middle turbinate||3(6.98%)||2(4.65%)||0.66|
|Inferior turbinate hypertrophy||5(11.63%)||3(6.98%)||0.486|
|Expansion of sphenoidalostia||33(76.74%)||2(4.65%)||<0.001|
|Bony dehiscence of lateral wall||8(18.60%)||1(2.32%)||0.018|
|Bony dehiscence of sphenoidal septum||2(4.65%)||6(13.95%)||0.16|
|Bony dehiscence of sellar floor||1(2.32%)||15(34.88%)||<0.001|
Table 1: Comparison of structural abnormalities, variants, and alterations to adjacent structures between the study group (n=43) and the control group (n=43)
There was no significant correlation between the direction of nasal septal deviation and the ipsilateral occurrence of SSFB in study group (p=0.861, Table 2).
|Direction of NSD||Laterality of SSFB||p value|
Table 2: Analysis of the correlation between the direction of nasal septal deviation (NSD) and the ipsilateral occurrence of SSFB.
The angles of nasal septal deviation ranges from 2.37o to 15.23o (mean=6.72±2.88o), and the percentage of mild, moderate and severe deviations were 16.28% (n=7), 72.09% (n=31) and 11.63% (n=5) respectively. No statistically significant difference could be detected between the severity of nasal septal deviation and the ipsi-lateral occurrence of SSFB (p=0.442, Table 3).
|Laterality of SSFB|
Table 3: Analysis of the impact of severities of nasal septal deviation on the laterality of occurrence of SSFB. Mild, moderate and severe represents the severities of nasal septal deviation.
On CT image, the expansion of sphenoidalostia was identified in 33 patients (76.74%, Figure 1A). The bony wall sclerosis was identified in 42 patients (97.67%, Figure 1B). Among the 42 patients with sclerosis of the bony wall of the sphenoid sinus, there were 34 patients (79.1%) whose sclerosis were mainly located at the lateral wall of sphenoid sinus. Moreover, the occurrence of the bony dehiscence of the lateral wall (Figure 2A) and the sphenoidal septum (Figure 2B) was in 8 patients (18.6%) and 2 patients (4.7%), respectively. However, no symptoms of nerve stimulation or intracranial infection occurred in these 10 patients.
Punctate calcificationswere observed in 31 patients (72.09%) based on CT scan (Figure 3A). The central signal deficiency on T2WIMRI (Figure 3B) could be detected in all 43 patients with SSFB (100%).
Symptoms of SSFB are often non-specific, and with the advancement of imaging techniques, diagnosis has improved and incidental cases uncovered . The etiology and pathogenesis of maxillary fungal sinusitis have been well described . The role of structural abnormalities on formation of SSFB, however, has not been fully assessed . In the present study, analysis of the correlation between the nasal septal deviation and the formation of SSFB was performed, which may be beneficial for better appreciation of the structural factors on pathogenesis of SSFB.
The laterality preponderance on the occurrence of a fungal ball in maxillary sinus was not observed [16,17]. In the present study, we detected that the occurrence of SSFB in the left side was more than that in the right side. Despite that the incidence of lesion distribution in the non-dominant sinus cavity was higher than that in the dominant sinus cavity, no significance difference could be detected (p>0.05). We therefore speculate that the volume of the sphenoid sinus may not be a predisposing factor for occurrence of SSFB.
One of the hypothesized predisposing factors for formation of fungal ball is the occlusion of ostia . The subsequent anaerobic environment caused by ostia occlusion might aggravate the inflammation and edema within the sinus . However, the expansion of sphenoidalostia was a typical sign on CT scans in our case series. The expanded ostia may correlate with the excretion of the fungal element within the sphenoid sinus once the fungal ball has reached a large size. Through the retrospective analysis of related symptoms, we found that more than half of the patients (65.12%) with posterior nasal drip had expanded ostia on CT scans . We therefore speculated that the expanded ostia may help alleviate the inflammatory burden within the sphenoid sinus to some extent, which may also contribute to posterior nasal drip .
Structural abnormalities of the nasal cavity might become the predisposing factors on formation of sinusitis . In the present study, the incidence of nasal septal deviation in patients with SSFB was statistically higher than that in the control group (Table 1). Through statistical analysis, however, there was no statistically significant difference between the direction and severity of nasal septal deviation on the ipsilateral occurrence of the sphenoidalfungal sinusitis (Tables 2 and 3). Therefore, the nasal septal deviation may not contribute to the development of sphenoidal fungal sinusitis , which was also in accordance with our previous studies that nasal septal deviation did not contribute to the formation of sinusitis from an aerodynamics perspective [10,23].
Neurovascular structures such as the optic nerve, internal carotid artery and cavernous sinus were located adjacent to the lateral wall of the sphenoidal sinus, and the sellar floor partiallyconstitutes the superior wall of the sphenoid sinus. With respect to the characteristics of sphenoidal fungal sinusitis on CT scan , Kim et al. reported that 95.6% of patients with sphenoidal fungal ball had sclerosis of the sinus wall, 60.9% had enlarged sinus, 60.9% had erosion of the inner sinus wall, and 69.6% had punctate calcification on CT scan (n=29) [3,18]. In the present study (n=43), the percentage of bony sclerosis was 95.3%, which mainly located at the lateral wall of the sphenoid sinus; the bony dehiscence occurred at the lateral wall and the sphenoidal septum of patients with sphenoidal fungal sinusitis were 18.6% and 4.7% respectively, the incidence of which was lower than that in Kim’s study [3,18] Of note, it is still difficult to differentiate the secondary bony deficiency from the congenital one just from the image analysis.
The discomfort in the ipsilateral face or the teeth, and the odour smelling were the major complaint of patients with maxillary fungal sinusitis . In patients with SSFB, however, the predominating symptoms were the headache, posterior nasal drip, and discomfort around the eye . There were few patients complaining the odour smell in nasal cavity in this study. According to previous studies with respect to the airflow distribution in the nasal cavity, the alteration of the self-smelling between the fungal lesions in maxillary sinus and the sphenoidal sinus may be correlated with the airflow distribution and the location of the olfactory mucosa [26,27]. It is more difficult for the transfer of the odour (airflow) from posterior section (sphenoethmoidal recess) than that from anterior portion (middle meatus) into the olfactory groove .
In addition to the typical sign of punctate calcification on CT image, the signal deficiency at the central part of the sphenoid sinus on T2WI MRI was another typical sign for differential diagnosis of patients with SSFB. In this retrospective analysis, we found that the punctate calcification on CT scan were typically in accordance with the signal deficiency on T2WI MRI scans. Moreover, for patients without typical sign of punctate calcification, the signal deficiency on T2WI was also present. As such, when the solitary sphenoidal lesion was suspected and the diagnosis cannot be ascertained on CT, the MRI may therefore be an alternative means for differential diagnosis .
There are significant limitations to this study. First, the relationship between the nasal septal deviation and the occurrence of sphenoidal fungal ball was retrospectively analyzed in essence, and a crosssectional analysis incorporating the inflammation or allergy status of the mucosa in addition to the structural abnormalities in future would be beneficial for better appreciation of the pathogenesis of SSFB. Second, SSFB is uncommon and increased numbers or a multiinstitutional study with larger sample size may provide higher level of evidence that this study did not have enough power to uncover.
Nasal septal deviation was common in patients with SSFB. However, no statistically significant difference was detected between the direction and severity of nasal septal deviationon the ipsilateral occurrence of the sphenoidalfungal sinusitis.
Declaration of Conflicting Interest
N. London holds stock in Navigen Pharmaceuticals and was a consultant for Cooltech Inc. The other authors declare no additional disclosures.
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