Inpatient Mortality After Endoscopic Sinus Surgery for Invasive Fungal Rhinosinusitis

OBJECTIVES:

Invasive fungal rhinosinusitis is a rare, life-threatening condition that affects the paranasal sinuses. The standard of care after diagnosis includes surgical debridement and aggressive medical management. Despite treatment, mortality remains unacceptably high. Most data are derived from small cohort experiences, with limited identification of mortality risk factors in the acute setting. The authors used a large national database to better understand clinical factors associated with inpatient mortality for this challenging condition.

METHODS:

Using the 2000-2014 National (Nationwide) Inpatient Sample database, the authors identified 979 adult patients with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of mucormycosis or aspergillosis and a procedure code of sinus surgery. Multivariate imputation by chained equation was performed to account for missing data, followed by multivariate logistic regression to identify predictors of inpatient mortality.

RESULTS:

In total, 979 adult patients were identified, with a median age of 57 years. The inpatient mortality rate was 15.8%. The most prevalent comorbidity was hematologic disorders (42.9%). Mucormycosis versus aspergillosis was associated with increased odds of inpatient mortality (odds ratio, 2.95; 95% confidence interval, 2.00-4.34; P < .001). The odds of inpatient mortality were significantly increased between patients with hematologic disorders and those without (odds ratio, 1.92; 95% confidence interval, 1.08-3.39; P = .024). Diabetes (odds ratio, 0.53; 95% confidence interval, 0.34 - 0.80; P = .003) was associated with the lowest odds of inpatient mortality.

CONCLUSIONS:

This represents the first population-based study evaluating the factors associated with inpatient mortality. These findings support prior observations demonstrating that the underlying immune dysfunction and type of fungal infection are important predictors of early mortality.

Acute Invasive Fungal Rhinosinusitis: Frozen Section Histomorphology and Diagnosis with PAS Stain

Acute invasive fungal rhinosinusitis (AIFRS) is a fulminant infection in immunocompromised patients requiring rapid diagnosis (DX), frequently made on frozen section (FS) of sinonasal biopsies, followed by prompt surgical debridement. However, FS interpretation is often difficult and DX sometimes not possible. In this study we sought to characterize reasons for misinterpretation and methods to improve diagnostic accuracy. The FS slides from 271 biopsies of suspected AIFRS in a 16-year period were reviewed and the morphologic features evaluated for their utility in DX. Recurring specific patterns of necrosis were identified, which to our knowledge have not been described in the literature. Although they provide strong evidence for AIFRS, identifying fungus consistently in necrotic tissue is essential for DX. Clues to identifying fungus and pitfalls in misidentification were identified, but even with expert knowledge of these, a gap in accurate DX remained. The key to FS DX of AIFRS is to improve fungus identification in necrotic tissues. Methods had been sought in the past to stain fungus at FS without consistent success. The Periodic Acid Schiff's Reaction for Fungi was modified by our histopathology department for use on frozen tissue (PASF-fs) resulting in effective staining of the fungus. It stained fungus on all 62 positive slides when applied retrospectively over hematoxylin and eosin (H&E) stained FSs and used prospectively at FS for DX. Although knowledge of histologic morphology on FS is important, the crucial value of this study is the novel use of PASF-fs to identify fungus in the DX of AIFRS.

[Histopathological Diagnosis of Fungal Sinusitis and Variety of its Etiologic Fungus]

 Fungal sinusitis is divided into two categories depending on mucosal invasion by fungus, i.e., invasive and noninvasive. Invasive fungal sinusitis is further divided into acute and chronic disease based on time course. Noninvasive fungal sinusitis includes chronic noninvasive sinusitis (fungal ball type) and allergic fungal sinusitis. Chronic noninvasive sinusitis is the most predominant fungal sinusitis in Japan, followed by allergic fungal sinusitis. Invasive fungal sinusitis is rare. Hyphal tissue invasion is seen in invasive fungal sinusitis. Acute invasive fungal sinusitis demonstrates hyphal vascular invasion while chronic invasive fungal sinusitis usually does not. Fungal tissue invasion is never found in noninvasive sinusitis. A fungal ball may exist adjacent to sinus mucosa, but its hyphae never invade the mucosa. Fungal balls sometimes contain conidial heads and calcium oxalate, which aid in identifying the fungus in the tissue. Allergic fungal sinusitis is characterized by allergic mucin that is admixed with numerous eosinophils and sparsely scattered fungal elements. Histopathology is important in classifying fungal sinusitis, especially in confirming tissue invasion by the fungus.

Invasive Fungal Rhinosinusitis: What is the Appropriate Follow-Up?

Background

Early detection and aggressive surgical and medical management have been associated with higher overall survival rates among patients with invasive fungal rhinosinusitis (IFS). With improved survival comes the question of how to appropriately manage these patients once disease stability has been achieved. Previous reports suggest follow-up only as long as the patients remain immunocompromised. This study attempts to answer the question of long-term clinical follow-up and suggests a regimen suitable for ensuring minimal posttreatment complications.

Methods

A retrospective review included all patients diagnosed with IFS between 1988 and 2004. The study group included patients who survived the initial treatment course, with at least 30 days of posttreatment follow-up of their IFS. Patient records were reviewed for significant complications, evidence of chronic sinus disease, the clinical status of their underlying medical comorbidities, and frequency and mode of follow-up.

Results

Thirteen patients were included. The average follow-up time was 633 days. Significant complications included one patient with acute bacterial sinusitis with resultant visual loss and one patient with chronic osteomyelitis of the orbit and skull base. Six of 13 patients had persistent chronic bacterial rhinosinusitis with crusting and bone sequestration. All complications were noted to occur after initial IFS eradication was thought to have taken place.

Conclusion

Significant complications of IFS can occur after medical remission and recovery of immune competence. Patients with IFS should be followed long term until remucosalization of the sinuses, resolution of crusting, and cessation of bony sequestration has occurred.

Acute Invasive Fungal Rhinosinusitis in Immunocompromised Patients: Role of an Early Diagnosis

Objective

The aims of the present study were to evaluate the clinical significance of the delay for surgical treatment and the prognostic value of other clinical, pathologic, and microbiological variables among hematologic patients affected by acute invasive fungal rhinosinusitis (AIFRS). Furthermore, we propose our early diagnosis and treatment protocol, reporting its 10-year results.

Study Design

Monocentric retrospective analysis.

Setting

The study was conducted from 2001 to 2017 at the University Hospital of Bologna, Italy.

Subjects and Methods

The impact of time to treatment and clinical, pathologic, and microbiological variables were analyzed among patients with histologically and microbiologically proven AIFRS. The outcomes of patients treated before the introduction of the early diagnosis protocol were compared with those treated afterward.

Results

Nineteen patients affected by AIFRS were eligible for the study. Treatment delay >4 days ( P = .002), infection caused by Mucorales ( P = .015), and extension of the disease were negative prognostic variables ( P = .017). The application of our protocol significantly reduced the delay for diagnosis and appropriate treatment by an average of 7.3 days ( P = .02).

Conclusion

The promptness of the diagnosis and surgical treatment may play a significant role in the management of AIFRS, as it appears to be significantly associated with the disease outcome. Our protocol may help to reduce the time required for diagnosis of high-risk hematologic patients.

Complete surgical resection and short-term survival in acute invasive fungal rhinosinusitis

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is a fulminant fungal infection seen in patients who are immunocompromised. Due to its rarity, there is little evidence regarding the appropriate antifungal treatment regimen, especially the degree of surgical intervention.

OBJECTIVE

To assess factors that impact short-term survival in AIFR as defined by survival to hospital discharge and to develop a staging system to predict survival and complete surgical resection.

METHODS

Fifty-four patients with histopathologically diagnosed AIFR who met inclusion criteria were identified between 1984 and 2014. Patient characteristics, disease extent, treatment modality, and short-term survival data were collected. Univariate analysis was performed to assess for factors associated with survival and increased likelihood of surgical resection.

RESULTS

Of 52 patients with adequate documentation, 36 (69.2%) survived their hospital stay. Complete surgical resection was the only factor associated with improved survival (survival, 95.5%; p < 0.01). A surgical staging system was proposed to guide probability of complete resection and overall prognosis, with stage I disease limited to the nasal cavity, stage II involving the paranasal sinuses, stage III involving the orbit, and stage IV with skull base or intracranial extension. The χ2 analyses showed a decreased likelihood of complete surgical resection with stage III or IV disease compared with stage I (resection, 90.9%) (stage III resection, 37.5% [p = 0.01]; stage IV resection, 16.7% [p = 0.002]). There was a decreased likelihood of survival associated with increasing disease stage compared with stage I (survival, 100%) (stage II survival, 60% [p = 0.009]; stage III survival, 62.5% [p = 0.02]; stage IV survival, 54.6%, [p = 0.006]).

CONCLUSION

Although further studies are needed to define specific treatment protocols, analysis of these data indicated that endoscopic sinus surgery with the goal of complete surgical resection may provide the best survival outcomes in select patients when complete surgical resection can be performed. Our staging system represents the first attempt to predict surgical success and prognosis in patients with AIFR.

Invasive fungal sinusitis: treatment of the orbit

PURPOSE OF REVIEW

To summarize diagnostic techniques for invasive fungal rhinosinusitis and provide a review of treatment options once disease has spread to the orbit.

RECENT FINDINGS

Improved imaging criteria, polymerase chain reaction and other serologic tests show promise in advancing our ability to accurately diagnose invasive fungal disease. Currently, there exists three treatment options for infected orbital tissue: exenteration, conservative debridement and transcutaneous retrobulbar injection of amphotericin B. Exenteration, the most frequently reported intervention, has not been proven to enhance survival. Conservative debridement and transcutaneous retrobulbar injection of amphotericin B are increasingly considered reasonable first-line options.

SUMMARY

Although investigative tools are improving, invasive fungal rhinosinusitis can still pose a diagnostic challenge. No one treatment option for the orbit has been proven superior to another. Therefore, it is justified to initiate therapy by prioritizing less morbid procedures. If deterioration is continually noted, more invasive interventions can then be employed. The treatment algorithm established at our institution is provided.

Imaging Spectrum of Invasive Fungal and Fungal-like Infections

Invasive fungal and fungal-like infections contribute to substantial morbidity and mortality in immunocompromised individuals. The incidence of these infections is increasing-largely because of rising numbers of immunocompromised patients, including those with neutropenia, human immunodeficiency virus, chronic immunosuppression, indwelling prostheses, burns, and diabetes mellitus, and those taking broad-spectrum antibiotics. Invasive fungal pathogens include primary mycotic organisms such as Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, and Paracoccidioides brasiliensis, which are true pathogens and inherently virulent. Secondary mycotic organisms such as Candida and Aspergillus species, Cryptococcus neoformans, Pneumocystis jirovecii, and Mucorales fungi are opportunistic, less virulent pathogens. Nocardia and Actinomyces species are gram-positive bacteria that behave like fungi in terms of their growth pattern and cause fungal-like invasive indolent infections; thus, these organisms are included in this review. Fungal and fungal-like infections can affect a variety of organ systems and include conditions such as meningitis, sinusitis, osteomyelitis, and enteritis. As awareness of these infections increases, timely diagnosis and treatment will become even more important. Imaging has a critical role in the evaluation of disease activity, therapy response, and related complications. Using an organ-based approach with computed tomography, magnetic resonance imaging, and ultrasonography to gain familiarity with the appearances of these infections enables timely and accurate diagnoses. ^©RSNA, 2017.

Posttransplant Lymphoproliferative Disorder: Otolaryngological Manifestations and Management

Objective

Posttransplant lymphoproliferative disorder (PTLD) is a unifying term for a spectrum of lymphoid expansion entities brought about by immunosuppression and is strongly associated with Epstein-Barr virus (EBV). Otolaryngological findings tend to present early in the clinical course; therefore, disease awareness among otolaryngologists is of utmost importance. This review synthesizes the body of literature pertaining to PTLD involving the head and neck, summarizes contemporary management, and highlights areas for future research.

Data Sources

PubMed/Medline.

Review Methods

Primary literature search of the Medline database was performed for all titles published in the past 10 years pertaining to PTLD. The database search included PTLD combined with a collection of otolaryngological MeSH terms. Full manuscripts were reviewed based on relevance of their title and abstract. Selection into this review was according to clinical and scientific relevance.

Conclusion

Adenotonsillar focus is common in children in whom adenotonsillectomy may be diagnostic and prevents potentially morbid airway obstruction. Sinonasal PTLD may mimic fungal infection. Laryngotracheal involvement predominately presents in children with symptoms of airway obstruction. PTLD limited to the esophagus is rare. Oral PTLD is rare and phenotypically varied. Cutaneous presentation of PTLD is infrequent, yet one-third of cases affects the head and neck. PTLD may present as cervical lymphadenopathy.

Implications for Practice

PTLD consideration is vital when evaluating posttransplant patients. Children and EBV-seronegative patients should receive otolaryngological follow-up after transplant. PTLD treatment is multidisciplinary and typically led by lymphoma specialists. Formal partnerships between otolaryngologists and transplant centers may improve patient care and research quality.

Acute Rhinosinusitis in Immunosuppressed Children: Diagnostic and Therapeutic Management

BACKGROUND

Immunosuppressive therapy places pediatric patients at risk of developing life-threatening sinonasal infections. Diagnosis and treatment are challenging owing to nonspecific signs and symptoms. The aim of this study was to present our department's experience with the surgical management of acute rhinosinusitis in immunosuppressed children.

METHODS

The records of all children with a hematologic or oncologic disease who underwent endoscopic sinus surgery (ESS) for acute rhinosinusitis from January 2005 to May 2014 were reviewed. Data were retrospectively collected on demographics, clinical and imaging characteristics, microbiology, pathology, treatment and outcome.

RESULTS

Thirty-four-immunosuppressed children underwent ESS for acute rhinosinusitis. Most patients had a fungal infection. Nineteen patients died at the end of follow-up; 10 deaths were infection-related. Facial swelling was the only symptom that correlated with death of infection. Relapse of the underlying disease, bone marrow transplantation, and long duration of neutropenia correlated with infection-related mortality. Fungal infection, and specifically Aspergillus, correlated with death from infection.

CONCLUSIONS

ESS is a safe and efficient procedure for diagnosing and treating immunosuppressed pediatric patients with acute rhinosinusitis. Early detection and aggressive medical and surgical treatment, with control of underlying risk factors, are crucial to improve outcome.

Complications of sinusitis

BACKGROUND

Sinusitis is a common disorder associated with significant patient symptomatology that adversely affects quality of life. Sinusitis can cause further morbidity and mortality through its impact on comorbid disorders, progression of inflammation, and extension of infection.

OBJECTIVE

This review highlights common complications of acute bacterial rhinosinusitis (ABRS) and chronic rhinosinusitis (CRS).

RESULTS

ABRS is complicated by orbital infections, such as pre- or postseptal cellulitis, and by intracranial infections, including abscesses of the epidural and subdural spaces. CRS can contribute to asthma, sleep disordered breathing, and smell disorders. CRS can be complicated by development of allergic fungal rhinosinusitis or deformity of surrounding bony structures. Fungal complications contribute to morbidity and mortality.

CONCLUSION

Complications of ABRS, although relatively rare, can cause significant morbidity and mortality, and must be promptly recognized. CRS commonly complicates or drives comorbid diseases, which adversely impacts quality of life. Treatment of these complications often requires coordinated multidisciplinary care.

Secondary free-flap reconstruction following ablation for acute invasive fungal sinusitis

OBJECTIVE

Acute invasive fungal sinusitis (AIFS) is a frequently fatal infection for which extensive and debilitating surgical debridement is a mainstay of therapy. Resulting defects are often composite in nature, mandating free tissue-transfer reconstruction. Outcomes data for free flap reconstruction are limited. The purpose of this study was to examine surgical outcomes and survival in patients undergoing free flap transfer following invasive fungal sinusitis.

STUDY DESIGN

Retrospective case series.

METHODS

Between 1995 and 2015, patients undergoing operative debridement for AIFS were identified. Surgical records were used to identify survivors of acute infection who subsequently underwent free flap reconstructive surgery. Patient demographics, cause of immune compromise, defect description, flap type, perioperative complications, indications for revision surgery, functional outcomes, and long-term survival were reviewed.

RESULTS

Forty-four patients were treated for AIFS, of those, 30 (68%) survived acute infection. Ten patients underwent maxillectomy, six with orbital exenteration, and were designated candidates for reconstruction. Eight patients underwent reconstruction. Median time from debridement to reconstruction was 67.5 days. Flap types included latissimus dorsi, scapula, anterolateral thigh, rectus, radial forearm, and fibula. Median follow-up was 7.7 months. No perioperative complications were encountered, and all subjects remained disease-free, able to speak and eat normally without prosthetic supplementation. Seven patients (87%) are currently alive.

CONCLUSION

Reconstruction of defects left by invasive fungal sinusitis using free-tissue transfer resulted in successful flap survival, with no disease recurrence for all defects and flap types reviewed. Survivors of AIFS are able to tolerate midface reconstruction, with favorable functional outcomes and survival rates.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:815-819, 2017.

Acute invasive fungal rhinosinusitis: Survival analysis and the prognostic indicators

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is a highly mortal, progressive fungal infection of the paranasal sinuses and surrounding structures that is almost always seen in patients who are immunocompromised. Despite the use of newer antifungal treatments and early diagnosis, the prognosis of AIFR does not improve significantly. Due to the higher incidence of patients who are immunocompromised and have more complex disease, AIFR is a growing medical issue in tertiary medical centers.

OBJECTIVE

The aim of this study was to present the outcomes and analyze the prognostic indicators of patients with AIFR who underwent surgery.

METHODS

Between October 2009 and November 2014, 37 patients who underwent surgery for AIFR at a tertiary care university hospital were included in the study. Overall survival and disease-specific mortality and survival rates were calculated to estimate survival function. The impact of age, sex, underlying disease, extent of AIFR, applied medical treatment, and causative species (mucormycosis, aspergillosis) were also taken into consideration. Also, the effect of a variety of laboratory parameters, such as hemoglobin, leukocyte, neutrophil, lymphocyte, platelet, and C-reactive protein (CRP) levels, to survival were evaluated.

RESULTS

The median follow-up time was 58 days (interquartile range = 304). Overall and disease-specific mortality rates were 64.9 and 51.4%, respectively. Fever was the most common symptom (86.5%), along with nasal obstruction and/or fullness (48.6%) and epistaxis (48.6%). Age and sex did not have a significant impact on survival (p > 0.05). Palate involvement was significantly associated with mortality (p < 0.05). According to the results of Cox, regression analysis for disease-specific mortality rate, leukocyte and neutrophil counts as well as CRP levels had a significant effect on survival function (p < 0.05).

CONCLUSIONS

Palatal involvement was associated with a higher mortality in our study. Also, leukocyte counts, neutrophile counts, and CRP values had a significant impact on survival function. The reversal of the underlying disease and immunosuppression is as important as the medical and surgical treatment.

Acute invasive fungal rhinosinusitis: our experience with 18 cases

Acute invasive fungal rhinosinusitis (AIFRS) is a rapidly progressive life threatening infection that is seen most commonly among immunocompromised patients. We present a case series of 18 patients clinically and histopathologically diagnosed with AIFRS with a mean follow-up of 9.11 ± 2.51 months (range 6-17). Demographic data, apparent symptoms and signs, underlying disorders, and outcomes are discussed. The mean age was 39.56 ± 20.66 years (range 2-75). The most common underlying diseases were diabetes mellitus (50 %) and leukemia (44.44 %). Mucosal biopsy confirmed fungal invasion of the nasal mucosa in all cases. The main fungi were Rhizopus oryzae (55.56 %), Absidia mucor (16.67 %), and Aspergillus fumigatus (27.78 %). Headache and facial pain (77.8 %), facial paresthesia (55.6 %), and ophthalmoplegia (33.3 %) were the most common symptoms and signs. Computed tomography and endoscopic findings showed various stages of sinonasal (100 %), pterygopalatine fossa (55.56 %), orbital (44.45 %), and cerebral (5.56 %) involvement. All patients underwent serial surgical debridement (3.78 ± 1.80 times; range 2-8) simultaneously with systemic antifungal therapy and proper management of the underlying disease. The most extreme case with brain involvement survived and recovered with no evidence of recurrent disease following treatment. All patients were considered cured after two endoscopic negative histopathologic evaluations. Three patients (16.67 %) died, one from uncontrolled leukemia and two due to renal failure. AIFRS is a potentially fatal condition, however, early diagnosis and management of the underlying disease accompanied with systemic antifungal and aggressive serial surgical intervention appears to be effective in reducing mortality in most patients.

An evaluation of invasive fungal sinusitis outcomes with subsite analysis and use of frozen section analysis

BACKGROUND

Invasive fungal sinusitis (IFS) is an aggressive mycosis of the nasal cavity with frequent extension to adjacent structures. Occurring more commonly in immunocompromised individuals, prognosis is typically poor despite aggressive treatment. This study aims to examine postoperative outcomes and survival of a cohort of fungal sinusitis patients at an academic center, as well as identify causes of death in IFS patients.

METHODS

This study was a retrospective chart review of patient charts and departmental records, yielding patient demographics, medical and surgical treatments, pathology records, and outcomes data.

RESULTS

Twenty-seven patients were identified from departmental records between 1998 and 2014. Twenty-one patients presented with Mucor infections, whereas the remaining 6 patients had Aspergillus. All patients were immunocompromised: diabetes (n = 14) and hematologic malignancy (n = 13). Three patients had multiple causes of immunosuppression. Most commonly involved subsites were the maxillary, ethmoid, and sphenoid sinuses. Nasal septum involvement was independently associated with mortality (p < 0.01). Overall mortality was 57.7% within 1 year, although 66.7% of fatalities occurred within 1 month of diagnosis.

CONCLUSION

Overall survival for IFS remains poor. Widespread disease and nasal septum involvement were associated with a negative clinical course. Early identification and aggressive surgical and antifungal therapy is warranted. Even despite intense therapy, comorbid conditions and drug toxicity increase mortality and complicate the clinical course.

Acute Invasive Fungal Rhinosinusitis: A 15-Year Experience with 41 Patients

OBJECTIVES

To describe a 15-year single-institution experience of 41 cases of acute invasive fungal sinusitis (AIFRS), identify clinical indicators predictive of AIFRS, and discuss our approach to these high-acuity patients.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral center; The Pennsylvania State University Hershey Medical Center.

SUBJECTS AND METHODS

A retrospective review was performed for AIFRS consultations between September 1999 and March 2014. Variables reviewed included underlying condition, presenting symptoms, absolute neutrophil count, disease extent on examination, radiographic findings, medical treatment, biopsy results, surgical treatment, and outcomes. Univariate analysis was performed to determine variables significantly associated with AIFRS. Outcome measures were assessed and patient assessment algorithm developed.

RESULTS

Of 131 patients evaluated, 41 were diagnosed with AIFRS; 92.7% had an underlying hematologic malignancy. Disease predictive variables included absolute neutrophil count <500/μL (P < .0001; sensitivity = 78%), mucosal abnormalities of middle turbinate (P < .0001; specificity = 88%) and septum (P < .0001; specificity = 97%), and specifically, necrosis of the middle turbinate (P < .0001; specificity = 97%). Twenty-five AIFRS patients (61%) survived until discharge; 25% (n = 10) expired secondary to AIFRS infection explicitly.

CONCLUSION

This series represents one of the largest single-institution experiences of AIFRS published to date. Timely diagnosis is necessary to improve patient outcomes and limit morbidity. Maintaining a high index of suspicion in at-risk patient populations, followed by prompt evaluation and management, is crucial in suspected AIFRS. The presence or absence of certain findings appear to correlate with biopsy results and may aid in appropriately gauging clinical suspicion for the presence of AIFRS.

Invasive fungal rhinosinusitis in adult patients: Our experience in diagnosis and management

BACKGROUND

This paper describes our experience in the management of acute and chronic invasive fungal rhinosinusitis (IFRS) in adults.

METHODS

Medical files of all patients aged >18 years treated in our institutions for IFRS from 2002 to 2013 were retrospectively reviewed.

RESULTS

A total of 18 cases (10 acute and 8 chronic) were recorded. In acute form, haematological malignancies represented the principal comorbidity (100%), while in chronic form this was diabetes mellitus (87.5%). All patients received systemic antifungal agents. Endoscopic sinus surgery was performed in 16/18 patients (88.9%). Among patients with an acute IFRS, 4/10 died of fungal infection (40%), on the other side 2/8 patients with chronic IFRS died of the evolution of the mycosis (25%).

CONCLUSIONS

Acute and chronic IFRS are different entities: in acute form, prognosis is poor, so therapy should be promptly performed, although host immune status and evolution of the haematological disease are key factors for the outcome. In chronic form, a wide surgical excision of the disease is recommended in order to obtain a complete removal of fungal infection. In both forms, early clinical findings are non-specific and ambiguous, so diagnosis depends on a high index of suspicion, taking into account predisposing factors.

The successful use of amphotericin B followed by oral posaconazole in a rare case of invasive fungal sinusitis caused by co-infection with mucormycosis and aspergillus

We report on an unusual case of oro-rhinocerebral disease caused by mucormycosis and aspergillus co-infection in a 54-year-old insulin dependent diabetic patient. Although she was successfully treated with parenteral amphotericin B followed by oral posaconazole, she was left with irreversible blindness of the right eye and multiple cranial nerve palsies.

Fungal Sinusitis

Fungal sinusitis is characterized into invasive and noninvasive forms. The invasive variety is further classified into acute, chronic and granulomatous forms; and the noninvasive variety into fungus ball and allergic fungal sinusitis. Each of these different forms has a unique radiologic appearance. The clinicopathologic and corresponding radiologic spectrum and differences in treatment strategies of fungal sinusitis make it an important diagnosis for clinicians and radiologists to always consider. This is particularly true of invasive fungal sinusitis, which typically affects immuno compromised patients and is associated with significant morbidity and mortality. Early diagnosis allows initiation of appropriate treatment strategies resulting in favorable outcome.

Invasive mould sinusitis in patients with haematological malignancies: a 10 year single-centre study

OBJECTIVES

Invasive mould sinusitis (IMS) is a severe infection in patients with haematological malignancies. Because of a paucity of contemporaneous data about IMS, we sought to evaluate clinical aspects and outcome of IMS in these patients.

METHODS

The records of adult haematological malignancy patients with proven or probable IMS over a 10 year period were reviewed retrospectively.

RESULTS

We identified 44 patients with IMS. Mucorales were isolated in 13 (35.1%) patients and Fusarium and Aspergillus were isolated in 9 (24.3%) patients each. Patients with IMS owing to Mucorales were more likely to have a history of diabetes mellitus (P = 0.003) and high-dose corticosteroid use (P = 0.03). Thirty-five (80%) patients received antifungal combinations and 36 (82%) underwent surgical debridement. The 12 week IMS-attributable mortality was 36.4% (16 patients). A relapsed and/or refractory haematological malignancy was an independent risk factor for 6 week IMS-attributable (P = 0.038), 12 week all-cause (P = 0.005) and 12 week IMS-attributable (P = 0.0015) mortality. Neutrophil count <100/µL and lymphocyte count <200/µL were associated with increased 12 week IMS-attributable and 6 week all-cause mortality, respectively (P = 0.044 and 0.013). IMS due to Aspergillus was an independent risk factor for both 12 week all-cause (P = 0.011) and IMS-attributable (P = 0.026) mortality. Initial antifungal therapy with a triazole-containing regimen was associated with decreased 6 week all-cause (P = 0.032) and IMS-attributable (P = 0.038) mortality. Surgery was not an independent factor for improved outcome.

CONCLUSIONS

Despite combined medical and surgical therapy, IMS had high mortality. Mortality risk factors were relapsed and/or refractory malignancy, cytopenia and Aspergillus infection in this study.

Acute Invasive Fungal Rhinosinusitis: A Comprehensive Update of CT Findings and Design of an Effective Diagnostic Imaging Model

BACKGROUND AND PURPOSE

Acute invasive fungal rhinosinusitis carries a high mortality rate. An easy-to-use and accurate predictive imaging model is currently lacking. We assessed the performance of various CT findings for the identification of acute invasive fungal rhinosinusitis and synthesized a simple and robust diagnostic model to serve as an easily applicable screening tool for at-risk patients.

MATERIALS AND METHODS

Two blinded neuroradiologists retrospectively graded 23 prespecified imaging abnormalities in the craniofacial region on craniofacial CT examinations from 42 patients with pathology-proven acute invasive fungal rhinosinusitis and 42 control patients proved negative for acute invasive fungal rhinosinusitis from the same high-risk population. A third blinded neuroradiologist decided discrepancies. Specificity, sensitivity, positive predictive value, and negative predictive value were determined for all individual variables. The 23 variables were evaluated for intercorrelations and univariate correlations and were interrogated by using stepwise linear regression.

RESULTS

Given the low predictive value of any individual variable, a 7-variable model (periantral fat, bone dehiscence, orbital invasion, septal ulceration, pterygopalatine fossa, nasolacrimal duct, and lacrimal sac) was synthesized on the basis of multivariate analysis. The presence of abnormality involving a single variable in the model has an 87% positive predictive value, 95% negative predictive value, 95% sensitivity, and 86% specificity (R(2) = 0.661). A positive outcome in any 2 of the model variables predicted acute invasive fungal rhinosinusitis with 100% specificity and 100% positive predictive value.

CONCLUSIONS

Our 7-variable CT-based model provides an easily applicable and robust screening tool to triage patients at risk for acute invasive fungal rhinosinusitis into a disease-positive or -negative category with a high degree of confidence.

Prognostic Factors for Survival in Patients with Acute Invasive Fungal Rhinosinusitis

Background

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive opportunistic infection with a high mortality rate. There are few reports that demonstrate an improvement in the overall prognosis. Furthermore, definite prognostic factors related to patient survival remain unclear.

Objective

The objective of this study was to evaluate the various clinical factors related to survival of patients with AIFR.

Methods

This is a retrospective case series with patients treated for AIFR between 1997 and 2013. A total of 45 patients with AIFR were enrolled for analysis. We evaluated demographics, clinical characteristics, and disease course.

Results

Mean age of patients was 59.6 years. AIFR developed most commonly in patients with immunocompromised host, such as diabetes (n = 23) or hematologic malignancy (n = 17). There were two main genera of fungus, Aspergillus (n = 30) and Mucor (n = 14). Headache, cranial neuropathy, visual loss, and orbital pain were the most common presenting symptoms. Overall survival was 53%. Underlying hematologic malignancy and diabetes were significantly associated with overall survival, and accompanying severe neutropenia and elevated C-reactive protein (CRP) were also related to poor prognosis. Initial presentation with facial swelling, involvement of nasal septum, or shorter symptom duration was also associated with survival reduction. Multivariate analysis revealed that CRP more than 5.50 mg/dL (Hazard ratio [HR], 9.04; p = 003) was an independent prognostic factor in patients with AIFR.

Conclusions

Overall survival rate remained approximately 50% in patients with AIFR. The prognosis of AIFR is significantly influenced by underlying diseases, accompanying neutropenia, CRP levels, symptom duration, involvement of septum, and the presence of facial swelling. Elevation of CRP, in particular, was an independent predictor of poor outcomes and should be monitored appropriately.

A novel fungus concentration-dependent rat model for acute invasive fungal rhinosinusitis: an experimental study

Background

Acute invasive fungal rhinosinusitis is a lethal infectious process afflicting immunocompromised individuals. Knowledge about this disease is still limited due to the scarcity of animal models designed to study the pathogenesis of this infection. Mast cells are tissue-resident immune cells that participate in a variety of allergic and inflammatory conditions. Limited attention has been given to the role of mast cells in acute invasive fungal rhinosinusitis. Therefore, the objectives of this study were to create a rat model of acute invasive fungal rhinosinusitis based on analyzing the impact of different fungal concentrations on establishing infection, and to observe the changes of mast cells in rats with this disease.

Methods

Sprague–Dawley rats were divided randomly into four groups, three of which were experimental and received different concentrations of Aspergillus fumigatus inoculations, and one was a control group (D). The inoculated Aspergillus fumigatus concentrations were 5 × 10⁷ conidia/ml in group A, 10⁷ conidia/ml in group B, and 10⁶ conidia/ml in group C. Before fungal inoculation, rats were immunosuppressed using cyclophosphamide and cortisone acetate, and had Merocel sponges inserted into the right nares. Hematology and histopathology investigations were then performed.

Results

An acute invasive fungal rhinosinusitis rat model was established successfully with an incidence rate of 90% in group A, 50% in group B and 10% in group C. Aspergillus fumigatus invasion was observed in 20% of the lungs in group A, but was not seen in the remaining groups. In addition, no fungi invaded the orbital tissue, brains, livers, spleens or kidneys of any rat. Compared with the control set, the total number of mast cells in the experimental groups was not significantly increased, but mast cell degranulation, on the other hand, was only found in infected nasal cavities.

Conclusions

This investigation illustrates that various fungal concentrations have different effects on the incidence of acute invasive fungal rhinosinusitis, and it also demonstrates the feasibility of using this model to study the process of fungal rhinosinusoidal invasion. In addition, the results suggest that mast cells may play a role in the protection of sinuses against acute Aspergillus fumigatus infection and in the clearance of established hyphal masses.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0713-y) contains supplementary material, which is available to authorized users.

Rhinosinusitis in hematopoietic stem cell-transplanted patients: influence of nasosinus mucosal abnormalities?

Introduction

Rhinosinusitis is characterized by inflammation extending from the mucosa of the nasal cavity into the paranasal sinuses. There are some aggravating features, such as immunosuppression, that can cause the nasal mucosal inflammation to linger for a long period, resulting in chronic or recurrent episodes. Such immunosuppression is the major feature of patients undergoing a hematopoietic stem cell transplant (HSCT); rhinosinusitis prevalence is higher in this group compared to immunocompetent patients. Nasal epithelial abnormalities have been described in, and may have some influence over, recurrent sinus infections among those patients. However, it is not clear whether rhinosinusitis can trigger mucosal abnormalities or whether a preexisting vulnerability for sinusitis recurrence is more likely. The objective of the study was to verify the influence of rhinosinusitis on nasal epithelial damage in patients undergoing hematopoietic stem cell transplantation.

Method

A total of 30 allogeneic HSCT patients were divided into two groups: 24 patients with chronic or recurrent rhinosinusitis and 6 patients without rhinosinusitis. These patients underwent a biopsy of the uncinate process that was analyzed by transmission electron microscopy and optical microscopy.

Results

The nasal mucosa analysis by optical microscopy showed no significant abnormalities. The ciliary orientation was obviously normal in the transplanted patients without rhinosinusitis. There was a trend toward a difference in the amount of cilia (decreased) and the primary modification of the ultrastructure of transplanted patients with rhinosinusitis.

Conclusion

HSCT patients, with and without rhinosinusitis, showed no significant histological abnormalities, except for ciliary disorientation and a possible decrease in ciliary and ultrastructural abnormalities in HSCT patients with rhinosinusitis.

Chronic invasive sinus and intracerebral aspergillosis controlled by combination therapy with micafungin and a daily dose of 400 mg itraconazole oral solution

Chronic invasive aspergillosis of the sinus is frequently fatal in the absence of early surgical and chemotherapeutic intervention because of its invasion of vascular tissue. We attempted to control a case of inoperable invasive aspergillosis of the sinus with micafungin and itraconazole oral solution. We prescribed a daily oral dose of 400 mg of itraconazole, which is twice the usual dose, and monitored the serum concentration of the drug. Finally, we were able to control the spread of the lesion. This case indicates that combination therapy with micafungin and a daily dose of 400 mg itraconazole oral solution is an alternative treatment strategy for inoperable invasive aspergillosis of the sinus.

Impact of treatment time on the survival of patients suffering from invasive fungal rhinosinusitis

BACKGROUND

Invasive fungal rhinosinusitis is an uncommon disease with high mortality rates. There is currently no consensus on the best treatment timing. We studied the impact of the treatment timing on the survival of patients experiencing invasive fungal rhinosinusitis.

METHODS

We conducted a retrospective study of patients suffering from invasive fungal rhinosinusitis. The duration of symptoms, clinical presentations, clinical signs, diagnoses, treatments, and outcomes were collected.

RESULTS

It was observed that more than 70% of the mortalities occurred within the subgroup of patients who exhibited symptoms of the disease within 14 days before admission.

After adjusting for the confounders, the time taken to treat the patients was the most statistically significant predictor for mortality (P = 0.045). We found no significant relationships between mortality and its significant covariates, which included the underlying diseases (P = 0.91) or complications (P = 0.55).

CONCLUSIONS

Our study demonstrates that the time taken to treat the patients is an important determinant for the survival of patients who are afflicted with invasive fungal rhinosinusitis. The appropriate treatments should be administered within 14 days from the time the symptoms begin to manifest.

A whiff of trouble: tumours of the nasal cavity and their mimics

A range of disease entities can affect the nasal cavity, often presenting with variable and non-specific symptoms. There is considerable overlap between the clinical and radiological features of neoplastic and non-neoplastic entities. The nasal cavity is often included in routine imaging of the brain, middle ear, skull base, and paranasal sinuses and should be included as a critical review area. The definitive diagnosis is in most cases confirmed by histopathological analysis. However, this review highlights the role of imaging in identifying nasal cavity disease, eliciting features of aggressive or indolent behaviour, and helping to narrow the differential diagnosis, thus facilitating a systematic approach when reviewing the nasal cavity.

Chapter 8: Invasive fungal rhinosinusitis

Invasive fungal rhinosinusitis (IFRS) is a disease of the paranasal sinuses and nasal cavity that typically affects immunocompromised patients in the acute fulminant form. Early symptoms can often mimic rhinosinusitis, while late symptoms can cause significant morbidity and mortality. Swelling and mucosal thickening can quickly progress to pale or necrotic tissue in the nasal cavity and sinuses, and the disease can rapidly spread and invade the palate, orbit, cavernous sinus, cranial nerves, skull base, carotid artery, and brain. IFRS can be life threatening if left undiagnosed or untreated. While the acute fulminant form of IFRS is the most rapidly progressive and destructive, granulomatous and chronic forms also exist. Diagnosis of IFRS often mandates imaging studies in conjunction with clinical, endoscopic, and histopathological examination. Treatment of IFRS consists of reversing the underlying immunosuppression, antifungal therapy, and aggressive surgical debridement. With early diagnosis and treatment, IFRS can be treated and increase patient survival.

Invasive fungal rhinosinusitis versus bacterial rhinosinusitis with orbital complications: a case-control study

BACKGROUND

Invasive fungal rhinosinusitis with orbital complications (IFSwOC) is a life-threatening condition. The incidence of mortality has been reported to be up to 80 percent. This study was conducted to determine the risk factors, presentations, clinical, and imaging findings that could help to manage this condition promptly.

METHODS

We conducted a case-control study of 100 patients suffering from rhinosinusitis with orbital complications. The risk factors, clinical presentations, radiological findings, medical and surgical managements, durations of hospital stay, and mortality rate data were collected.

RESULTS

Sixty-five patients were diagnosed with IFSwOC, while the other thirty-five patients composed the control group. The most important risk factor for IFSwOC was diabetes mellitus. Visual loss and diplopia were the significant symptom predictors. The significant clinical predictors were nasal crust, oculomotor nerve, and optic nerve involvement. The CT findings of IFSwOC were sinus wall erosion and hyperdensity lesions. The mortality rate was 25.71 percent in the IFSwOC group and 3.17 percent in the control group.

CONCLUSIONS

Invasive fungal rhinosinusitis with orbital complications is symptomatic of a high mortality rate. The awareness of a patient's risk factors, the presenting symptoms, signs of fungal invasion, and aggressive management will determine the success of any treatment procedures.

Fungal rhinosinusitis and imaging modalities

This report provides an overview of fungal rhinosinusitis with a particular focus on acute fulminant invasive fungal sinusitis (AFIFS). Imaging modalities and findings that aid in diagnosis and surgical planning are reviewed with a pathophysiologic focus. In addition, the differential diagnosis based on imaging suggestive of AFIFS is considered.

The role of fungi in diseases of the nose and sinuses

BACKGROUND

Human exposure to fungal elements is inevitable, with normal respiration routinely depositing fungal hyphae within the nose and paranasal sinuses. Fungal species can cause sinonasal disease, with clinical outcomes ranging from mild symptoms to intracranial invasion and death. There has been much debate regarding the precise role fungal species play in sinonasal disease and optimal treatment strategies.

METHODS

A literature review of fungal diseases of the nose and sinuses was conducted.

RESULTS

Presentation, diagnosis, and current management strategies of each recognized form of fungal rhinosinusitis was reviewed.

CONCLUSION

Each form of fungal rhinosinusitis has a characteristic presentation and clinical course, with the immune status of the host playing a critical pathophysiological role. Accurate diagnosis and targeted treatment strategies are necessary to achieve optimal outcomes.

Invasive fungal rhinosinusitis: a 15-year experience with 29 patients

OBJECTIVES/HYPOTHESIS

Document a 15-year experience with 29 cases of acute invasive fungal rhinosinusitis (AIFR) and evaluate factors predictive of disease clearance and overall survival.

STUDY DESIGN

Case series with chart review.

METHODS

Patients were identified by review of department billing records between 1995 and 2010. Medical records were reviewed for patient demographics, disease characteristics, clinical course including surgical and medical therapy, treatment outcomes, and long-term survival.

RESULTS

Twenty-nine patients with AIFR were identified. Causes of immunosuppression included hematologic malignancy (n=16), diabetes (n=12), medication (n=10), and acquired immunodeficiency syndrome (n=1), with 10 patients having multiple causes of immunosuppression. Facial pain, swelling and orbital symptoms were the most common presenting symptoms. Fungal organisms included Mucor (n=18) and Aspergillus (n=10) species, with one patient infected with both. Disease-specific survival (DSS) from AIFR was 57%. Intracranial (P=.01) and ethmoid sinus (P=.05) involvement were significantly linked with short-term disease-related mortality. Overall survival (OS) at 6 months was 18%. For OS, intracranial involvement (hazard ratio [HR], 4.47; 95% confidence interval [CI], 1.51-13.22) and cranial neuropathy at presentation (HR, 3.2; 95% CI, 1.3-8.2) were significantly associated with shortened survival. Of the five patients surviving >6 months, two developed long-term major sinonasal complications.

CONCLUSIONS

DSS and OS remain low for patients with AIFR. Extensive surgical resection in patients with these poor prognostic signs should be considered carefully in light of their poor survival. Long-term survivors are at significant risk of sinonasal complications and should be followed closely.

Cervicofacial tissue infarction in patients with acute invasive fungal sinusitis: prevalence and characteristic MR imaging findings

INTRODUCTION

Tissue infarction is known as one of the characteristic features of invasive fungal sinusitis (IFS). The purpose of this study was to investigate the prevalence and characteristic MR imaging findings of cervicofacial tissue infarction (CFTI) associated with acute IFS.

METHODS

We retrospectively reviewed MR images in 23 patients with histologically or microbiologically proven acute IFS. CFTI was defined as an area of lack of enhancement in and around the sinonasal tract on contrast-enhanced T1-weighted images. We divided CFTI into two groups, i.e., intrasinonasal and extrasinonasal. Particular attention was paid to the location of extrasinonasal CFTI and the signal intensity of CFTI on T1- and T2-weighted images. The presence of bone destruction on CT scans was also recorded.

RESULTS

CFTI was found in 17 (74%) of 23 patients. All of these 17 patients had intrasinonasal CFTI, and 13 patients also had extrasinonasal CFTI. All 13 patients with extrasinonasal CFTI died of disease directly related to IFS. Various locations were involved in the 13 patients with extrasinonasal CFTI, including the orbit (n = 8), infratemporal fossa (n = 7), intracranial cavity (n = 3), and oral cavity and/or facial soft tissue (n = 4). Various signal intensities were noted at the area of CFTI on T1- and T2-weighted images. Bone destruction was found on CT scans in only 3 of 17 patients with CFTI.

CONCLUSION

CFTI with preservation of the bony wall of the involved sinonasal tract may be a characteristic MR imaging finding of acute IFS. The mortality is very high once the lesion extends beyond the sinonasal tract.

Neuro-ophthalmology of invasive fungal sinusitis: 14 consecutive patients and a review of the literature

BACKGROUND

Invasive fungal sinusitis is a rare condition that usually occurs in immunocompromised patients and often presents as an orbital apex syndrome. It is frequently misdiagnosed on presentation and is almost always lethal without early treatment.

DESIGN

Retrospective case series of 14 consecutive patients with biopsy-proven invasive fungal sinusitis from four tertiary hospitals.

PARTICIPANTS

Fourteen patients (10 men and 4 women; age range 46-82 years).

METHODS

Retrospective chart review of all patients presenting with invasive fungal sinusitis between 1994 and 2010 at each hospital, with a close analysis of the tempo of the disease to identify any potential window of opportunity for treatment.

MAIN OUTCOME MEASURES

Demographic data, background medical history (including predisposing factors), symptoms, signs, radiological findings, histopathological findings, treatment approach and subsequent clinical course were recorded and analysed.

RESULTS

Only one patient was correctly diagnosed at presentation. Only two patients were not diabetic or immunocompromised. The tempo was acute in two patients, subacute in nine patients and chronic in three patients. In the subacute and chronic cases, there was about 1 week of opportunity for treatment, from the time there was a complete orbital apex syndrome, and still a chance for saving the patient, to the time there was central nervous system invasion, which was invariably fatal. Only two patients survived - both had orbital exenteration, as well as antifungal drug treatment.

CONCLUSIONS

Invasive fungal sinusitis can, rarely, occur in healthy individuals and should be suspected as a possible cause of a progressive orbital apex syndrome.

Survival outcomes in acute invasive fungal sinusitis: a systematic review and quantitative synthesis of published evidence

OBJECTIVES/HYPOTHESIS

Acute invasive fungal sinusitis (AIFS) is an aggressive and often fatal infection. Despite improvements in medical and surgical therapy, survival remains limited and the factors that contribute to patient outcomes remain poorly understood. The current study systematically reviews and quantitatively synthesizes the published literature to characterize prognostic factors associated with survival.

STUDY DESIGN

Systematic review.

METHODS

Fifty-two studies comprising a total of 807 patients met inclusion criteria and were used for analysis of treatment, presentation, and outcomes. Univariate and multivariate logistic regression was used to identify prognostic factors.

RESULTS

All studies were classified as level 4 evidence, as per definitions provided by the Oxford Center for Evidence-Based Medicine. The most common presenting symptoms of patients with AIFS were facial swelling (64.5%), fever (62.9%), and nasal congestion (52.2%). Most patients were treated with a combination of intravenous antifungal medication and surgery. The overall survival rate was 49.7%. On univariate analysis, poor prognosis was associated with renal/liver failure, altered mental status, and intracranial extension. Patients who were diabetic, had surgery, or received liposomal amphotericin B had an improved chance of survival. On multivariate analysis, advanced age and intracranial involvement were identified as independent negative prognostic factors. Positive prognostic factors again included diabetes and surgical resection.

CONCLUSIONS

The overall mortality of patients with AIFS remains high, with only half of the patients surviving. Diabetic patients appear to have a better overall survival than patients with other comorbidities. Patients who have intracranial involvement, or who do not receive surgery as part of their therapy, have a poor prognosis.

LEVEL OF EVIDENCE

N/A.

Invasive facial fungal infections: Orofacial soft-tissue infiltration in immunocompromised patients

Invasive facial fungal infections affect the orofacial soft tissues in immunocompromised patients and can cause significant morbidity and mortality. Primary infection occurs from direct inoculation of the skin surface, while secondary infection occurs from extension from an adjacent sinonasal process. The imaging features of secondary infection are similar to acute fulminant invasive fungal sinusitis with infiltration of the orofacial soft tissues in combination with sinonasal disease. However, primary infection can occur in the absence of sinonasal disease, making diagnosis challenging. We present two cases, one of primary and one of secondary invasive facial fungal infection. Careful scrutiny of the orofacial soft tissues in immunocompromised patients is necessary to detect invasive facial fungal infections so that appropriate surgical and medical therapies can maximize patient outcomes.

Granulocyte transfusions in fulminant invasive fungal sinusitis

PURPOSE

Fulminant invasive fungal sinusitis (IFS) is an aggressive disease seen in patients who are severely neutropenic. The use of granulocyte transfusions to address neutropenia-associated IFS has been described for almost 2 decades. The objectives are to provide our experience using granulocyte transfusions in patients with IFS and to provide a current review of the literature.

MATERIALS AND METHODS

A retrospective chart review was performed at the Medical College of Wisconsin to identify patients who received granulocyte transfusions for IFS. Data collected included age, original diagnosis, IFS pathogen, dates, transfusion number, reason for discontinuation, additional therapies, last known follow-up, and status at last known follow-up. A Medline search and manual review of citations within bibliographies was also performed.

RESULTS

A total of 20 patients received granulocyte transfusions at the Medical College of Wisconsin between October 2003 and June 2009; 3 of these patients received granulocyte transfusions for fulminant IFS. A total of 22 reported cases of IFS treated with granulocyte transfusions exist in the current literature.

CONCLUSIONS

Although limitations to the use of granulocyte transfusions exist, they still represent a viable treatment option in individuals who fail to respond to more conventional therapies.

Endonasal treatment of acute invasive fungal rhinosinusitis in immunocompromised pediatric hematology-oncology patients

OBJECTIVES

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive fungal infection in immunocompromised patients with high mortality rates. The aim of this study is to present our experiences on endonasal treatment in immunocompromised pediatric hematology-oncology patients with AIFR.

METHODS

Thirteen pediatric hematology-oncology patients treated for AIFR between March 2006 and December 2011 were analyzed retrospectively. We reviewed the following data for all patients: age, gender, predisposing disease, initial symptoms, pathological diagnosis, microbiological results, laboratory findings, surgical procedure, number of operations and treatment outcomes.

RESULTS

Nine of 13 patients with lesions confined to sinonasal cavity were operated with endoscopic approach. Open surgery was performed in four patients, three of them had palatal and buccal lesions and one had facial skin involvement. Endoscopic approach was also used for sinonasal lesions of these four patients. A total of 7 patients died: 4 patients with progression of the underlying disease, 2 patients with sepsis and 1 patient due to renal failure. Survival rate in surgically treated patients was found 46% (6/13 patients).

CONCLUSIONS

Endonasal endoscopic approach is both feasible and efficient technique, also enables excellent local control with less morbidity compared to open surgery. This approach is suitable for patients who are diagnosed in the early stages of AIFR and also presents a less traumatic option for patients with poor health status. Open surgical procedure should be preferred in patients with disease extending out of the sinonasal cavity.