Invasive aspergillosis of the paranasal sinuses and orbit: can you save the eye?

Subtotal Petrosectomy: Pictorial Review of Clinical Indications and Surgical Approach

Subtotal petrosectomy (STP) is characterized by obliteration of the middle ear and occlusion of the external auditory canal. The advent of the endoscope has allowed a reduction in morbidity for some conditions such as cholesteatoma and other middle ear disorders, but STP still plays an important role. A retrospective review of medical records and videos of patients who had undergone STP was performed. Perioperative data and images were collected from various clinical cases who had undergone subtotal petrosectomy at our tertiary referral university hospital in Verona. We confronted our experience with a review of the literature to present the main indications for this type of procedure. STP allows a variety of diseases to be managed effectively as it offers the possibility of a definitive healing with radical clearance of temporal bone. Moreover, it can be safely combined with other procedures with a very low complication rate. Although the endoscope represents a revolution in ear surgery, STP, when indicated, is nowadays a surgical option that should be included in the otosurgeon's portfolio.

Successful Treatment of Optic Neuropathy Associated with Sphenoid Sinus Aspergillosis

PURPOSE

We report a case of optic neuropathy related to sphenoid sinus aspergillosis which showed good visual recovery with surgery and medical antifungal treatment.

METHODS

Observational case study Case Presentation A 62-year-old man presented with decreased visual acuity in the right eye for 3 weeks. His visual acuity was counting fingers in the right eye and 20/20 in the left eye. Relative afferent pupillary defects were detected in the right eye. Optic neuropathy related to invasive fungal sphenoid sinusitis was suspected via radiologic evaluation. Endoscopic sinus surgery was performed and histopathological examination revealed aspergillosis. Amphotericin B combined with ceftriaxone and metronidazole was started. After the fungal culture results were positive for the Aspergillus species, amphotericin B was changed to voriconazole. At 1 month after surgery, visual acuity improved to 20/25.

CONCLUSION

Appropriate radiologic evaluation can be helpful when optic neuropathy associated with a fungal infection is suspected, and timely surgical and medial treatment should be considered.

Orbital mycoses in an adult subtropical population

Background/objectives

To report the spectrum of fungal infections involving the orbit encountered in an Australian subtropical population with respect to presentation, host risk factors, involved pathogens, treatment and outcomes.

Subjects/methods

A retrospective chart review was performed on all adult patients with orbital mycosis treated by the senior author (TJS) from 1986 to 2017 in a tertiary setting.

Results

Thirty cases of fungal infection involving the orbit were included in this case series. Of these, 26 patients had invasive disease and four patients had non-invasive disease. Causative organisms included mucormycosis (16), aspergillus (8) and other fungi (7). Common risk factors included haematological disorders or malignancy, neutropenia, corticosteroid use and diabetes mellitus. Mucormycosis in three immunocompetent patients was caused by Apophysomyces elegans. Orbital apex syndrome was observed in approximately one third of patients at initial ophthalmological assessment. Amphotericin B was used in most cases of mucormycosis, while there was a more varied spectrum of anti-fungal use in other fungal infections. Seven patients with mucormycosis proceeded to orbital exenteration with a survival rate of 43%. No patients with other orbital fungal infections were exenterated.

Conclusions

Orbital mycoses are not only opportunistic but true pathogenic infections. While initial symptoms may be varied, the development of orbital apex syndrome should raise suspicion for this condition, regardless of patient immune status or age. Survival and visual outcomes are often poor with invasive disease. Multidisciplinary team management with early orbital specialist involvement is essential.

Fungal infections of the orbit

Fungal infections of the orbit can lead to grave complications. Although the primary site of inoculation of the infective organism is frequently the sinuses, the patients can initially present to the ophthalmologist with ocular signs and symptoms. Due to its varied and nonspecific clinical features, especially in the early stages, patients are frequently misdiagnosed and even treated with steroids which worsen the situation leading to dire consequences. Ophthalmologists should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of this invasive sino-orbital infection. In this review, relevant clinical, microbiological, and imaging findings are discussed along with the current consensus on local and systemic management. We review the recent literature and provide a comprehensive analysis. In the immunocompromised, as well as in healthy patients, a high index of suspicion must be maintained as delay in diagnosis of fungal pathology may lead to disfiguring morbidity or even mortality. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly oral voriconazole and topical amphotericin B, may be beneficial in selected patients.

Facial translocation approach for management of invasive sinonasal aspergillosis

Aspergillosis is an uncommon fungal disease seen commonly in paranasal sinuses. It may be of noninvasive variety which is restricted to paranasal sinuses seen in healthy and immunocompetent hosts or may present as invasive form seen in immunocompromised hosts especially in diabetics and patients under long term immunosuppressant therapy. Along with paranasal sinuses invasive forms may encroach upon surrounding adjacent structures involving the orbit and extend intracranially. Orbital and intracranial involvement have a high mortality rate. Early diagnosis of the lesion and prompt aggressive management is important for better prognosis. Aggressive treatment includes surgical debulking and medical management mainly with systemic amphotericin B and other azoles. In orbito-cranial involvement, due to limited access to cranial base, it becomes difficult to surgically debulk the lesion with safety to surrounding important structures. Facial translocation approach gives adequate access to paranasal sinuses, orbit and anterior cranial base. Reported here are two cases of invasive cranio-orbito-nasal aspergillosis treated with facial translocation approach.

Acute chiasmal abscess resulting from perineural extension of invasive sino-orbital aspergillosis in an immunocompetent patient

OBJECTIVE

Intracranially invasive sino-orbital aspergillosis is a rare entity seen predominantly in immunocompromised individuals. We report a unique case of an acute chiasmal abscess resulting from perineural extension of an indolent invasive sino-orbital aspergillosis in an immunocompetent patient.

CASE DESCRIPTION

A 61-year-old healthy Ukrainian man presented with severe left retro-orbital pain and a gradual ipsilateral monocular vision loss with rapid progression to a contralateral temporal visual field cut. He was found to have an intracranially invasive sino-orbital Aspergillus fumigatus infection with perineural extension along the optic nerve complicated by an acute chiasmal abscess.

RESULTS

The patient was managed with surgical debridement and adjuvant antifungal chemotherapy. The patient's life and vision were preserved.

CONCLUSIONS

The case demonstrates that it is possible to successfully control advanced intracranial aspergillosis with tissue-sparing surgery and adjuvant antifungal chemotherapy in immunocompetent individuals.

A Case of Invasive Aspergillosis Presenting as Acute Angle Closure Glaucoma

Purpose: To report a case of invasive aspergillosis presenting as acute angle closure glaucoma. Case: A 72-year-old male patient visited our clinic with decreased visual acuity and ocular pain on the right eye lasting for 3 d. His intraocular pressure was 42 mmHg in the right eye and 18 mmHg in the left eye. And, there was about 2 mm of exophthalmos, slight ptosis with decreased motility in all directions, conjunctival injection, moderate mydriasis with a relative afferent pupillary defect, and angle closure in the right eye. Orbital computed tomography and magenetic resonance imaging showed isotense mass involving right orbit and ethmoid sinus. Based on the biopsy, invasive aspergillosis was definitely diagnosed. Despite perfoming peripheral laser iridotomy and administrating antifungal agent and antiglaucoma medication, the patient was blinded in his right eye. During the follow-up period, visual acuity in the left eye suddenly decreased due to the invasive aspergillosis in the left paranasal sinus and optic nerve, and eventually the patient lost his left vision as well. Conclusion: This report is regarding a case of an invasive aspergillosis resulting in blindness in both eyes with the clinical manifestations of acute angle closure caused by invasive aspergillosis.

Comparison of efficacy of amphotericin B and itraconazole in chronic invasive fungal sinusitis

Management of invasive fungal sinusitis includes both surgery and antifungal chemotherapy. To compare the efficacy of amphotericin B and itraconazole used alone in the management of chronic invasive fungal sinusitis. A prospective randomized unblinded study was conducted in the Department of Otolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India during December 2006 to June 2008. 26 immunocompetent patients were randomly divided into two groups-group A-received amphotericin B and group I-received itraconazole in conventional doses. The response to treatment was judged on the basis of symptomatic and radiologic resolution. Seven patients had complete cure (5/16-gr I; 2/10-gr A); Eleven patients had persistent disease (7/16-group-I; 4/10 in group A); four relapses were noted (3/16 in group I and 1/10 in group A); 3 deaths occurred; one patient was lost to follow up. Relative risk analysis did not show any statistically significant difference between the two drugs as regards their efficacy. Itraconazole and amphotericin B both have been found to be equally efficacious in the management of invasive fungal sinusitis. Itraconazole however, has fewer side effects compared to amphotericin B.

Multiple head and neck tumors following treatment for craniopharyngioma

To report a unique case of a patient with multiple head and neck tumors following treatment for craniopharyngioma. Retrospective review of the medical record. There is an association between radiation treatment for primary intracranial malignancies and the subsequent development of other intracranial tumors. At the same time, reports regarding the association between thyroid cancer and radiation exposure are abundant within the literature. We present a unique case of a young female who underwent resection and radiation treatment for a craniopharyngioma in 1988. With the exception of bitemporal visual loss and panhypopituitarism requiring hormone replacement therapy, the patient had a relatively uneventful course until 2005. At that time, she developed hearing loss and incapacitating vertigo, which was ultimately attributed to a temporal bone Langerhans histiocytosis. A year and a half later, she was noted to have a thyroid nodule, the pathology of which revealed papillary carcinoma. Seven months after that, she developed new auditory and vestibular symptoms attributable to an acoustic neuroma. This case is remarkable because neither Langerhans histiocytosis following radiation of a craniopharyngioma nor this distinctive combination of head and neck tumors in general have ever been previously reported.

Malignancies of the ear in irradiated patients of nasopharyngeal carcinoma

OBJECTIVES/HYPOTHESIS

To report on the clinical profiles and treatment experiences of patients with second primary ear malignancy after treatment of nasopharyngeal carcinoma (NPC).

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective review of the clinical outcomes and pathology of 11 irradiated NPC patients who subsequently had second primary malignancies of the ear at a single institution.

RESULTS

Ten tumors were squamous cell carcinoma and one tumor was chondrosarcoma occurring within the radiation field of previous treatment for NPC. The interval between previous radiotherapy and diagnosis of ear malignancy was 3 to 27 years with a median time of 17 years. Six tumors were located in the external auditory canal, two in the middle ear cavity, two in the periauricular region and one in the mastoid cavity. Four patients underwent surgery, and the other seven patients underwent surgery plus adjuvant radiotherapy. The 3-year disease-free and overall survival rates were 30.3% and 20%, respectively.

CONCLUSIONS

Postirradiated malignancy of the ear is extremely rare, but is one of the causes of death for NPC long-term survivors despite curative-intended treatment with surgery plus adjuvant radiotherapy is instituted.

Combination antifungal therapy for invasive aspergillosis: can it replace high-risk surgery at the skull base?

OBJECTIVE

The increasing volume of literature on Aspergillus sinus infection is confusing because different authors stress different aspects of the disease. It is generally accepted that standard therapy consists of surgical debridement and medication with systemic amphotericin B. Patients who fail the standard therapy or those who cannot tolerate amphotericin B pose a dilemma. This study attempted to address the issues concerning combination therapy in invasive aspergillosis.

MATERIALS AND METHODS

We conducted a prospective randomized study on 6 apparently immunocompetent patients with invasive aspergillosis complicated by orbital and intracranial spread. All the patients were treated with a combination of amphotericin B (2.5 g) and itraconazole (6 months). They were monitored clinically and radiologically before, during, and after their combined antifungal therapy management.

RESULTS

Among the 6 immunocompetent patients, orbital involvement was seen in 5, skull base erosion with intracranial extension was seen in 2, and infratemporal fossa extension was seen in 2. After completion of treatment with 1.5 g of amphotericin, the paranasal sinus part of the lesion disappeared. However, there was residual lesion in the intracranial part that completely disappeared only after treatment with 2.5 g of amphotericin and 6 months of itraconazole therapy.

CONCLUSIONS

Invasive aspergillosis has been increasingly reported among immunocompetent patients. No single surgical or medical maneuver, including orbital exenteration, guarantees cure. The combination of amphotericin B and itraconazole for skull base aspergillosis represents a real step forward in the treatment of invasive aspergillosis.

The invasive and saprophytic syndromes due to Aspergillus spp

Aspergillus spp. produce a wide range of invasive and sapropytic syndromes which may involve any tissue. Within a given tissue or organ the pathology and pathogenesis varies enormously, ranging from angioinvasive disease to noninvasive saprophytic disease. The individual invasive and saprophytic syndromes in which a causative role can be attributed to Aspergillus spp. are detailed specifically with reference to the underlying pathology and pathogenesis, the clinical setting and features, and the manner in which a diagnosis can be established.

The outcome of radical surgery and postoperative radiotherapy for squamous carcinoma of the temporal bone

OBJECTIVES/HYPOTHESIS

The objective was to analyze the clinical data and outcome of all the patients treated surgically for squamous carcinoma of the temporal bone in a tertiary referral department of skull base surgery over a 20-year period.

STUDY DESIGN

Retrospective.

METHODS

Thirty-nine patients with squamous carcinoma of the temporal bone were analyzed. The patients were staged according to the University of Pittsburgh system. The surgical technique, reconstruction of the surgical defect, postoperative radiotherapeutic treatment, follow-up regimen, and results were all described in detail.

RESULTS

Disease-free survival for T2N0M0 tumors or stage II disease was 100%. The survival for stage III disease was also 100%. Overall, T3 tumors resulted in 50% survival. Overall, survival for stage IV tumors 34.3%, and for T4 tumors, 38%.

CONCLUSION

The overall disease-free survival for the entire series was 43.2%. Node-positive disease, poorly differentiated squamous cell histological findings, brain involvement, and salvage surgery were associated with a poorer outcome. The improved survival (66%) of patients treated de novo in the study series compared with those treated with salvage surgery (33%) suggested that early referral and aggressive primary surgical treatment with postoperative radiotherapy offer the greatest chance of cure.

Radiation-induced malignancy of the head and neck

OBJECTIVE

Our goal was to evaluate our experience with radiation-induced malignancy (RIM), compare that experience to the literature, and review treatment modalities.

STUDY DESIGN AND SETTING

The setting is the University of Kansas Medical Center. A retrospective review was performed to identify patients with RIM. Patients were included if they met the criteria for RIM as delineated in the literature.

RESULTS

Thirteen patients met the criteria for RIM. The mean latency period was 22 years. Sarcomas were the most common type of RIM and the paranasal sinuses were the most common location. Surgical resection was our treatment of choice.

CONCLUSIONS

Our patient series differs from previous reports in that sarcomas were the predominating RIM and the paranasal sinuses were the most common location. We noted a shorter latency period than has been previously published. Surgical excision is the treatment of choice.

EBM RATING

C.

Squamous cell carcinoma of the temporal bone

Squamous cell carcinoma of the temporal bone is a rare, highly malignant, aggressive disease in an extremely difficult anatomic site with a very poor prognosis. The development of an evidence base for the efficacy of its treatment has been hampered by its rarity. This article reviews current opinion based on the recent literature.

Glioblastoma multiforme occurring in a patient treated with gamma knife surgery

✓ Stereotactic radiosurgery is being increasingly advocated as the primary modality for treatment of vestibular schwannomas (VS). This modality has been shown to arrest tumor growth, with few associated short-term morbidities, and with possibly better hearing and facial nerve preservation rates than microsurgery. Radiation-induced oncogenesis has long been recognized, although stereotactic radiosurgery de novo induction of a secondary tumor has never been clearly described. The authors report on a patient with a VS who did not have neurofibromatosis Type 2 and who underwent gamma knife surgery (GKS). This patient required microsurgical removal of the VS within 8 months because of development of a tumor cyst with associated brainstem compression and progressive hydrocephalus. The operation resulted in clinical stabilization and freedom from tumor recurrence.

Seven and a half years after undergoing GKS, the patient presented with symptoms of raised intracranial pressure. Magnetic resonance imaging demonstrated a new ring-enhancing lesion in the inferior temporal lobe adjacent to the area of radiosurgery, which on craniotomy was confirmed to be a glioblastoma multiforme (GBM). Despite additional conventional external-beam radiation to the temporal lobe, the GBM has progressed. Whereas this first reported case of a GBM within the scatter field of GKS does not conclusively prove a direct causal link, it does fulfill all of Cahan's criteria for radiation-induced neoplasia, and demands increased vigilance for the potential long-term complications of stereotactic radiosurgery, and reporting of any similar cases.

Malignancy of the Temporal Bone and External Auditory Canal

A retrospective study of 18 patients with malignant tumors of the external auditory canal and temporal bone was undertaken to gain an Asian perspective of this rare disease. Of these patients, 15 (83%) had squamous cell carcinoma (SCC) and 61% had stage T3 tumors at presentation. The mean age was 56 years (range 38-82 years). Seven (39%) of the 18 patients had radiation-associated tumors (RATs), and all had undergone radiotherapy for treatment of nasopharyngeal carcinoma. The 1-year cumulative recurrence for the RAT group was 100%, but there was no recurrence in the non-RAT group ( P = 0.001). In malignancies of the external auditory canal and temporal bone, a different classification and staging system for patients with RATs may be warranted to better guide treatment strategies.