of acute invasive fungal rhinosinusitis - our experience with 21 patients

: Objective- Acute invasive fungal rhinosinusitis (AIFR) is a rapidly progressive disease, which usually develops in patients with uncontrolled diabetes mellitus (DM) and immunocompromised patients. The purpose of this study was to look retrospectively at the clinical profile, management and outcome of these patients. Study design- Retrospective chart review Settings- Tertiary care hospital Materials and methods- A retrospective chart review was done of patients diagnosed with AIFR between the years 2006 to 2011. RESULTS- Among the 21 patients, 17 (80.9) had uncontrolled diabetes mellitus. Nasal obstruction was the predominant symptom (16 patients, 76.2 percent). Mucosal changes were most commonly observed in the middle meatus (18 patients, 85.7 percent) and rhino-orbital disease was the most common presentation (11 patients, 52.4 percent). The most common causative fungal agent was Rhizopus (16 patients, 76.2 percent). Multiple surgeries were required in all except those patients who underwent endoscopic debridement with orbital exenteration. The mortality rate was 14.3 percent (3 patients). Conclusions- Early and aggressive surgical debridement, intravenous amphotericin B and prompt treatment of the underlying disease are the mainstay of AIFR treatment. Orbital involvement leads to higher mortality. Early orbital exenteration in patients, when indicated, has a better outcome because of reduced intracranial spread. Long term follow up and multiple surgical debridements when required, particularly in those who have not had orbital exenteration, are essential for a good outcome. diseases and diseases resulting in immunosuppresed state like hematologic malignancies, aplastic anemia, long term steroid use and acquired immunodeficiency syndrome are predisposing factors for the development of AIFR. (3,10) There is an increased risk of developing AIFR in bone marrow and solid organ transplantation patients, due to use of chemotherapeutic agents and immunosuppressive drugs. 3 Neutropenic patients are more likely to have invasive Aspergillosis than Mucor. 11 The most common predisposing factor in our study was poorly controlled diabetes mellitus. Patients with diabetes may succumb rapidly to the disease because of late diagnosis. 11 Conclusions: Diabetic and immunocompromised patients with history of nasal symptoms and eye symptoms should be evaluated for the possibility of AIFR at the earliest. As initial symptoms and radiological features are nonspecific, rigid nasal endoscopic examination and biopsies with fungal culture of mucosal and submucosal tissues from suspected sites should be performed as early as possible. Based on positive fungal smear report and suspected clinical features, Amphotericin B should be administered. Early endoscopic debridement is essential if disease is limited to sinonasal region to limit further progression of the disease. Maxillectomy and orbital exenteration may be required in cases of extensive necrosis (intraorbital extension, palatal involvement). Orbital involvement leads to higher mortality. Orbital exenteration, when indicated, leads to a good outcome. Early and aggressive surgical debridement, intravenous amphotericin B and prompt treatment of underlying disease are the mainstay of AIFR treatment. Long term follow up and multiple surgical debridements when required, particularly in those who have not had orbital exenteration, are essential for a good outcome.