Validate the classification of fungal rhinosinusitis: A retrospective analysis of 162 patients at a single institution

Invasive fungal rhinosinusitis: current evidence and research opportunities

PURPOSE OF REVIEW

To summarize the evidence surrounding diagnosis, treatment, prognosis, and surveillance of patients with acute invasive fungal sinusitis (AIFS) and discuss future research needs.

RECENT FINDINGS

New risk factors for AIFS such as COVID have been identified, and a new prognostic staging system has been developed.

SUMMARY

Most patients who develop AIFS are immunocompromised, with the majority having a history of diabetes or a hematologic malignancy. Unfortunately, there are not any highly sensitive and specific diagnostic tools. Therefore, a combination of signs and symptoms, imaging, endoscopy, biopsy, and labs should be used to diagnosis AIFS. Although surgery and systemic antifungals are known to improve outcomes, there is limited data on time to intervention, duration of antifungals, and surveillance patterns. There is also limited information on factors that can predict outcomes in AIFS patients. However, sensory/perceptual changes, prolonged neutropenia duration, and comorbidity burden may be associated with a poor prognosis.

Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations

BACKGROUND

Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS.

METHODS

The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated.

RESULTS

A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains.

CONCLUSION

Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.

Invasive Fungal Rhinosinusitis with and without Orbital Complications: Clinical and Laboratory Differences

Background: Invasive fungal rhinosinusitis (IFS) is a rare but often fatal disease. There are limited studies regarding IFS with orbital complications (IFSwOC). The present study aimed to identify the clinical signs associated with IFSwOC and prognosticators of the disease. Methods: A retrospective case series was conducted of patients histopathologically confirmed IFS or fungal rhinosinusitis with clinically apparent neuro-orbital complications who underwent surgery between 2008 and 2018. Demographic data, presenting symptoms and signs, culture data, laboratory results, and patient outcomes were obtained from medical records. Results: A total of 38 patients were identified, including 9 patients with IFSwOC, and 29 patients with IFS without orbital complications (IFSsOC). The clinical signs associated with developing orbital complications include headache, fever, sphenoid sinus, or posterior ethmoid sinus involvement, CRP level ≥ 1.025 mg/dL, or ESR level ≥ 46.5 mm/h. In IFSwOC group, male, posterior ethmoid sinus involvement, WBC count ≥ 9000 μL, CRP level ≥ 6.91 mg/dL, or ESR level ≥ 69 mm/h were correlated with a significantly poorer prognosis. Conclusion: IFS patients with sphenoid or posterior ethmoid sinus involvement, headache or fever as presenting symptoms, elevated CRP, and ESR level were at risk of developing orbital complications. Timely surgical debridement followed by systemic antifungal treatment may improve treatment outcomes.

Acute Invasive Fungal Rhinosinusitis-Related Orbital Infection: A Single Medical Center Experience

Backgrounds

Acute invasive fungal rhinosinusitis (AIFRS) is a hazardous infectious disease with rapid progression and high mortality and morbidities. Further orbital involvement is commonly seen. This study aims to analyze risk factors, clinical characteristics, and outcomes between patients with or without orbital involvement.

Methods

A retrospective review was performed in a single tertiary medical center over a span of 13 years (2005–2018). A total of 21 patients with diagnosis of AIFRS were enrolled. We reviewed the patients' basic characteristics, comorbidities, clinical presentations, image study findings, culture pathogens, and treatment outcomes and analyzed the differences between orbital-involved and orbital sparing disease.

Results

The most common comorbidities in AIFRS were diabetes mellitus (DM) and hematological malignancy. Nine the 21 AIFRS patients had orbital-involved disease. Patients with orbital involvement had a higher prevalence of DM (p < 0.05). Image studies revealed significant infection of the ethmoid sinus, sphenoid sinus, and frontal sinus in the group with orbital complication (p < 0.05). Mucor, Rhizopus, and Aspergillus were cultured in both groups. Five patients in the orbital involvement group expired, with all of them having an initial presentation of conscious disturbance (p < 0.01). Rhino-orbital-cerebral fungal infection was noticed in 3 of the 5 expired patients.

Conclusion

In AIFRS patients, DM other than hematological malignancy was the main risk factor for orbital-involved disease. Patients with ethmoid, sphenoid, or frontal sinusitis had a higher possibility of orbital complication. Poor consciousness at initial presentation revealed highest possibility of rhino-orbital-cerebral fungal infection and led to death.