Facial translocation approach for management of invasive sinonasal aspergillosis

Abstract

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.

Keywords: Facial Translocation; Fungal sinusitis; Invasive Aspergillosis; Orbito-zygomatico-maxillary bone flap.

Fig. 1

Preoperative photograph showing swelling on right side and proptosis of right eye

Fig. 2

a CT scan demonstrating a large heterogeneously enhancing mass lesion, invading the right maxillary sinus, eroding its medial and lateral walls and extending up to right pterygoid plate. b Extension of the lesion in retro-orbital planes engulfing the optic nerve leading to proptosis

Fig. 3

Histologic section confirmatory of Aspergillosis

Fig. 4

Weber–Ferguson incision on right side

Fig. 5

Orbito-zygomatico-maxillary bone flap was removed temporarily for access to anterior cranial base

Fig. 6

Debridement of the fungal mass with preservation of optic nerve

Fig. 7

Orbito-zygomatico-maxillary bone flap plated back

Fig. 8

Reconstruction of the floor of orbit and anterior wall of maxillary sinus

Fig. 9

Postoperative photograph after 2 months

Fig. 10

T1 weighted MRI showing hypointense soft tissue lesion involving the right maxillary sinus, nasal cavity and the orbit extending up to the frontal lobe

Fig. 11

Standard facial translocation approach with midline split of the palate

Fig. 12

After debridement, retracted bone flap plated back