Definition and management of invasive fungal rhinosinusitis: a single-centre retrospective study

Abstract

Objectives: The purpose of this study was to correlate acute invasive fungal rhinosinusitis (AIFRS) and chronic invasive fungal rhinosinusitis with underlying diseases, aetiological microorganisms, clinical symptoms, radiological findings, and surgical and medical treatment to determine the subset of patients who require more accurate diagnostic investigation and to prevent irreversible complications.

Methods: This retrospective monocentric study included 17 patients who underwent endoscopic sinus surgery evaluated by paranasal computed tomography and magnetic resonance imaging. Age, sex and symptoms, and location of the invasive fungal infection and the causative fungus were analysed.

Results: In total, 4 patients were affected by the AIFRS form, and 13 by the chronic form. Diabetes mellitus was reported in 41.17% of cases, and haematological diseases in 23.52%. The maxillary sinuses were involved in 47.05% of cases and sphenoidal sinuses in 52.94%; Aspergillus fumigatus was the fungus in 76.47% of cases, and Zygomycetes in 23.53%.

Conclusions: An understanding of the different types of fungal sinusitis and knowledge of their features play a crucial role in reaching prompt diagnosis and initiation of appropriate therapy, which is essential to avoid a protracted or fatal outcome.

Keywords: Aspergillus; Mucormycosis; invasive fungal rhinosinusitis; isavuconazole; liposomal amphotericin B.

Figure 1.

Patient #2 in the AIFRS group – (A, B) Coronal CT scan shows an opacity of the right maxillary sinus (MS) with associated multiple foci of microcalcifications (white arrowhead) and sclerosis of the MS walls by reactive osteitis. Focal interruption (white arrow) of the lateral wall is also present. (C) Coronal T2-MRI shows marked hypointense signal with areas of hyperintense signal in the lateral and inferior recess of the MS. (D) Intraoperative view showing typical friable cheesy-like yellow to brown material on the floor of the maxillary sinus.

Figura 2.

Patient #4 in the AIFRS group – Axial (A) and coronal (B) CT scans display heterogeneous opacity of the sphenoid sinuses (SS) with associated microcalcification (white arrowhead), thickening and sclerosis of the bone surrounding the SS, and multiple interruptions of its bony wall (black arrow). (C) Axial gadolinium-enhanced T1-weighted MRI demonstrates a marked hypointense signal (asterisk) in the left SS with inflamed mucosa at the periphery. (D) Endoscopic removal of fungal concretion after opening the anterior wall of the left SS.

Figura 3.

Patient #1 in the AIFRS group – (A) Coronal CT scan showing complete opacification of the right sphenoid sinus with optical right nerve canal wall erosion (black arrows). (B) Axial MRI with contrast shows a hypointense signal in a large space-occupying lesion in the right SS extending into the right cavernous sinus (asterisk). The cavernous carotid artery appears unobstructed. (C) Endocranial mycotic abscess (white arrow) with inflamed mucosa within Meckel’s cave on the right at periphery at day 41. (D) Intraoperative view during endoscopic sinus surgery in the right SS. (E) Absence of motility of the right eye in lateral gaze related to the deficit of the right lateral rectus muscle for abducens nerve palsy.