Hirabayashi, Kristin E.; Idowu, Oluwatobi O.; Kalin-Hajdu, Evan; Oldenburg, Catherine E.; Brodie, Frank L.; Kersten, Robert C.; Vagefi, M. Reza
Purpose: Invasive fungal sinusitis is a rare but potentially lethal disease that primarily affects immunocompromised patients. The purpose of this study was to review an academic medical center’s experience in the presentation, diagnosis, and treatment of invasive fungal sinusitis.
Methods: A retrospective chart review was performed at a single institution over a 17-year period. Medical records, radiographic imaging, and operative reports were analyzed. Bivariate and multivariable analyses were performed to determine factors that affected visual acuity outcomes and mortality.
Results: Fifty-five patients with histopathologically confirmed invasive fungal sinusitis were included. The average duration of follow up was 1.8 ± 2.6 years (range: 1 week to 10 years). The most common causes of immunosuppression were hematologic malignancy (45%), diabetes (31%), and organ transplantation (9%). At presentation, 35% of individuals were neutropenic (absolute neutrophil count < 500/μl). All patients received systemic antifungal treatment. A surgical intervention was performed on 50 patients (91%), and all but one had functional endoscopic sinus surgery. Nine (16%) patients underwent orbital exenteration. Multivariable analysis of visual acuity outcomes demonstrated that individuals infected with Zygomycota had 6–7 lines worse vision than those infected with Ascomycota (mean difference in logMAR 0.66, 95% confidence interval 0.27 to 1.06, p = 0.001). Patients who had functional endoscopic sinus surgery had 7–8 lines better visual acuity than those without functional endoscopic sinus surgery (mean difference in logMAR −0.76, 95% confidence interval −1.13 to −0.38, p < 0.001). The overall death rate due to infection was 24%. Bivariate models demonstrated no difference in mortality in patients receiving exenteration versus those who did not (p = 0.14). Multivariable analysis of mortality demonstrated that neutropenia increased mortality (adjusted odds ratio 10.05, 95% confidence interval 1.49 to 67.67, p = 0.02). Having a greater number of surgeries was associated with an increased rate of survival (adjusted odds ratio 0.39, 95% confidence interval 0.15 to 0.96, p = 0.04).
Conclusions: Invasive fungal sinusitis is an aggressive disease with significant mortality. Patients with neutropenia had a lower rate of survival, and infection with Zygomycota was associated with worse visual acuity outcomes. Those having functional endoscopic sinus surgery had better final visual acuity, and an increased number of surgeries was associated with a decreased chance of death. Exenteration yielded no observed survival benefit.
Endoscopic sinus debridement portends better visual acuity outcomes in patients with invasive fungal sinusitis, whereas exenteration yields no difference in survival benefit.
Luke K. Chehade MBBS MIPH David Curragh BAO FRCOphth Alkis J. Psaltis PhD FRACS Dinesh Selva DHSc FRANZCO
No abstract available
Branson, Sara V.; McClintic, Elysa; Yeatts, R. Patrick
Purpose: To describe risk factors, clinical parameters, treatment, and prognosis for patients with septic cavernous sinus thrombosis presenting with orbital cellulitis.
Methods: Retrospective case series of 6 patients identified with septic cavernous sinus thrombosis and orbital cellulitis confirmed by magnetic resonance imaging at a tertiary care center from January 1980 to December 2016. Medical records were reviewed for demographics, risk factors, symptoms, etiology, radiographic diagnosis, complications, treatments, and outcomes. In addition, a literature review was performed from 2005 to 2018, and 119 cases of septic cavernous sinus thrombosis confirmed by imaging were included for aggregate comparison. This study adheres to the tenets of the Declaration of Helsinki, and institutional review board approval was obtained.
Results: All 6 cases presented with headache, fever, ocular motility deficit, periorbital edema, and proptosis. The primary source of infection included sinusitis (n = 4) and bacteremia (n = 2). Identified microorganisms included methicillin resistant Staphylococcus aureus (n = 3) and Streptococcus anginosus (n = 1). All cases were treated with broad-spectrum intravenous antibiotics and anticoagulation, and one case underwent endoscopic sinus surgery. The mean time between initial presentation to diagnosis of cavernous sinus thrombosis was 2.8 days, and the average length of hospital admission was 21 days. The mortality rate was 0%, but 4 cases were discharged with neurological deficits including vision loss (n = 1) and ocular motility disturbance (n = 3). Literature review produced an additional 119 cases.
Conclusions: Early diagnostic imaging with contrast-enhanced CT or MRI should be initiated in patients with risk factors and ocular symptoms concerning for cavernous sinus thrombosis. Treatment entails early administration of broad-spectrum intravenous antibiotics, anticoagulation, and surgical drainage when applicable.
Bothra, Nandini; Nayak, Arpita; Ali, Mohammad Javed
A 32-year-old male presented with a history of swelling in the right lacrimal sac region extending into the medial orbital region (Fig. A) of 18 months duration. He was a known case of fungal sinusitis (Aspergillus) and had undergone functional endoscopic sinus surgery 3 years ago with a suboptimal response. Subsequently, he had undergone a right external dacryocystorhinostomy (DCR) elsewhere 3 years ago. Endoscopic evaluation showed retained discharge with focal whitish lesions within the sinuses suggestive of a severe maxillary and ethmoid sinusitis. Dacryocystorhinostomy ostium was filled with a similar whitish lesion with discharge in the vicinity (Fig. B). CT scan of the orbits showed bilateral sinusitis involving the ethmoid, maxillary, and partly frontal sinuses with isodense mass lesion extending into the medial orbit through the DCR ostium and displacing the globe temporally (Fig. C,D). Biopsy of the sinus lesions, ostium cicatrix, and orbital lesion were similar on histopathology, which showed epitheloid granulomas formed of multinucleated giant cells, epitheloid histiocytes, and lymphoplasmacytic cells (Fig. E). Gomori methanamine stains showed the presence of fungal filaments (Fig. F). Because the orbital lesion was displacing the globe, it was debulked along with a concurrent treatment for fungal sinusitis.
It is a likely possibility that preexisting fungal sinusitis followed by DCR allowed the fungus to spread to the orbit through the bony ostium. Therefore, any preexisting sinusitis especially of fungal origin should be well treated before advising a lacrimal bypass procedure.
Silas, Megan R.; Jeffers, Johnathan V.; Farooq, Asim V.; Corey, Jacquelynne P.; Shah, Hassan A.
The authors report the use of a 0.35-mm-thickness nylon implant for medial orbital wall reconstruction to facilitate functional endoscopic sinus surgery (FESS) for severe erosive polypoidal sinus disease while minimizing iatrogenic injuries to the orbital contents. A retrospective chart review identified 4 patients with extensive polypoidal sinus disease who underwent medial orbital wall reconstruction in the setting of FESS. All patients underwent successful reconstruction of bilateral eroded medial orbital walls using a 0.35-mm Supramid Foil Nylon Implant immediately followed by FESS. There were no permanent complications or iatrogenic injuries to the orbital contents due to FESS. All patients experienced improvement in sinus symptoms. Medial orbital wall reconstruction in the setting of erosive polypoidal sinus disease is a useful tool to help facilitate FESS. It allows the sinus surgeon to clear sinus disease aggressively with the orbits being protected from iatrogenic injury.
Leung, Vannessa; Dunn, Hamish; Newey, Allison; O’Donnell, Brett Less
Sinusitis complicated by orbital apex syndrome is rare. The majority of cases are due to mucormycosis in immunocompromised patients. The authors report a case of orbital apex syndrome secondary to Pseudomonas sinusitis. The patient was a 79-year-old Type 2 diabetic woman who underwent left-sided functional endoscopic sinus surgery. Three months postprocedure, she presented with a 3-week history of gradual vision loss and constant temporal headache on the ipsilateral side. Examination revealed light perception vision, a relative afferent pupillary defect, absent corneal reflex, and disc pallor. Imaging revealed opacification of the posterior ethmoidal air cells extending to involve the orbital apex. Urgent orbital and sinonasal decompression was performed. Intraoperative specimens grew Pseudomonas aeruginosa. The patient was treated with liposomal amphotericin B, posaconazole, and piperacillin/tazobactam. The patient recovered with no visual sequelae. Pseudomonas is an important mimicker to consider in sinusitis causing orbital apex syndrome, and it may occur following functional endoscopic sinus surgery.
Alaraj, Ahmad M.; Al-Faky, Yasser H.; Alsuhaibani, Adel H.
Purposes: To study the ophthalmic manifestations of patients with allergic fungal sinusitis (AFS) and evaluate the importance of early diagnosis and management in preventing the possible future complications of AFS.
Methods: Retrospective chart review of 100 patients with the diagnosis of AFS from a single institution was performed. Age, gender, clinical presentation including ophthalmic and radiological findings, immune status, patterns of sinus involvement, medical and surgical intervention needed, laboratory results, and the course of the disease were evaluated.
Results: The mean age at presentation was 19.8 years (range, 10–42 years) with no clear gender predominance (52% of patients were female).The most common sinuses involved were ethmoid and maxillary sinuses. All patients underwent functional endoscopic sinus surgery and received systemic and topical steroids. There were no intervention-related complications. Thirty-four of 100 patients had ophthalmic consequences of AFS. The most common ophthalmic presentation was proptosis (n = 21, 61.7%), followed by epiphora (n = 5, 14.7%), visual loss (n = 4, 11.7%), diplopia (n = 3, 8.8%), and dystopia (n = 1, 2.9%) in addition to 1 patient having ptosis beside proptosis. CT scans of these 34 patients showed that 82.3% had nonhomogenous opacification of sinuses, 52% had erosion of lamina papyracea, 17.6% had intraorbital extension, and 8.8% had intracranial extension.
Conclusions: Ophthalmologists may be the first who encounter these patients which necessitates familiarity with AFS presentations and complications. In cases of sudden visual loss, early intervention may prevent permanent vision loss. Functional endoscopic sinus surgery and postoperative systemic and topical steroids resulted in dramatic improvement of ophthalmic symptoms and signs.
Cesare Zoia, Daniele Bongetta, Fabio Pagella, Elena R. Antoniazzi, Paolo Gaetani
However rare they may be, optic nerve sheath meningiomas are lesions that represent one-third of all intrinsic tumors of the optic nerve.1 When untreated, they can lead to blindness: Their surgical treatment, which is likewise a blinding procedure in most cases, is reserved for patients with exophtalmus.1 Another indication for surgery is to prevent their chiasmatic spread to the controlateral optic nerve.2 In recent years, endoscopic transnasal techniques have evolved to such an extent that now even the orbit can be reached with these types of approaches.
Elad Ben Artsi, Tamara Wygnanski-Jaffe, Benjamin Shalev, Abraham Spierer, Iftach Yassur, Ofira Zloto, Daphna Prat, Ayelet Priel, Guy Ben Simon
To present 6 cases of orbital trauma, diplopia and strabismus after functional endoscopic sinus surgery (FESS).
Retrospective observational case series.
The medical charts of suitable patients were reviewed for information on medical examination, imaging studies, the type of corrective surgery, and surgical outcomes.
All patients with diplopia and strabismus after undergoing FESS who were treated or consulted at our institution between 2008 and 2017 were included.
Main Outcome Measures
The presence and extent of strabismus and double vision at the end of follow-up.
Six patients complained of diplopia after FESS; all of them had proven orbital trauma. In Cases 1–5, patients suffered medial rectus (MR) muscle transection and subsequent exotropia. Their prognosis was guarded despite prompt surgical intervention, and ranged from large exotropia when direct recovery of the MR was attempted, to primary gaze orthotropia but with minimal adduction capacity, during which vertical recti transposition was attempted. Patient 6 sustained transient diplopia, although all of his extraocular muscles appeared intact on imaging. His eye position and movement were completely resolved with conservative measures only.
Our experience was that immediate recovery procedures to reattach the muscle in cases with proven transection of the MR muscle are futile, and that definitive corrective strabismus surgery (ie, vertical muscle transposition) has a better chance to achieve favorable results.
Vicinanzo, Matthew G.; Allamneni, Chaitanya; Deitz, Luke W.; Elsas, Frederick J.
Purpose: To describe autogenous fascia lata graft fixation as a novel method to treat exotropia related to medial rectus (MR) muscle injury following functional endoscopic sinus surgery.
Methods: Three consecutive patients with MR transection and exotropia after functional endoscopic sinus surgery were selected. Preoperative examination was performed; no MR function was noted for over 3 months after injury. CT and dynamic functional MRI were performed, where MR transection and medial wall breach were noted. An autogenous fascia lata graft was harvested and fixated from the remaining periosteum of the posterior-most extent of the medial orbital wall and attached to the globe at the MR insertion. In addition, an ipsilateral lateral rectus muscle recession was performed.
Results: Alignment of the eyes in primary gaze and downgaze was achieved and remained so at the 3-month postoperative examinations, with minimal head turn or prism correction (<5 prism diopters) necessary to control diplopia. Two patients required recession of the fascial graft for a minor overcorrection and have remained stable for over 6 months.
Conclusions: Severe exotropia secondary to MR damage following functional endoscopic sinus surgery is a known complication historically difficult to treat. Traditional surgical methods, including vertical muscle transposition, commonly result in complete recurrence of exotropia and increase risk of anterior ocular ischemia. Unlike simple nonabsorbable suture fixation, fascial grafts are completely biointegratable, do not result in significant inflammation, and are unlikely to rupture. Fascia lata graft fixation of the MR to the posterior orbital medial wall is a new and successful method to eliminate exotropia after MR injury.