Benefit of Endoscopic Surgery in the Management of Acute Invasive Skull Base Fungal Rhinosinusitis: Clinical Morbidity and Outcome in a 20-Year Period

Introduction: Acute fungal rhinosinusitis, often seen among immunocompromised patients, is a rapidly progressive, life-threatening condition associated with poor prognosis. Surgical debridement can be challenging when infection is associated with skull base extension. Recent studies have shown that aggressive endoscopic sinus surgery can be effective in removing invasive disease. We reviewed clinical characteristics of patients who underwent endoscopic surgical debridement of acute fungal rhinosinusitis to evaluate postoperative outcomes and risk for recurrence. We present a series of 14 patients with clinically and histopathologically confirmed skull base fungal rhinosinusitis who underwent pure endoscopic surgery.

Methods: We performed a retrospective analysis of patients with skull base fungal rhinosinusitis treated with an endoscopic surgical approach at our institution from 1998 to 2018. Demographic and clinical data including age, sex, underlying comorbidities, presenting symptoms, physical exam findings, radiologic findings, preoperative course, operative procedure, postoperative complications, number of debridements, histologic and microbiologic findings, length of stay, and postoperative course were reviewed.

Results: Fourteen patients underwent endoscopic removal of fungal sinusitis. Five patients (35.7%) were women and nine (64.3%) were men. Median age at the time of primary surgery was 66.1 years (range, 24.9–84.5). The most common underlying medical comorbidities were hematologic malignancy in nine (65.3%) patients and poorly controlled diabetes in seven (50%) patients. Mean HbA1c for diabetic patients was 7.7%. Presenting symptoms included headache (50%), eye pain (42.9%), facial pain (28.6%), visual changes (21.4%), and congestion (14.3%). One patient presented with left-side proptosis and a left cranial nerve six palsy. In another patient, fungal sinusitis was identified incidentally during MR stroke evaluation. Radiologic findings included hyperdensity of multiple sinuses (28.6%) and skull base erosion (21.4%). The most common fungi were Mucormycosis (42.9%) and Aspergillus (35.7%). Fungal cultures were obtained in all patients; nine (64.3%) demonstrated positive growth after 28 days of incubation. 71.4% of patients received preoperative antibiotics, 28.6% received preoperative antifungals, and 28.6% received preoperative steroids. Postoperatively, 98.9% of patients received antibiotics, 100% received antifungals, and 42.9% received steroids. Twelve (85.7%) patients underwent a purely endoscopic surgical approach, and two (14.3%) patients had a combined endoscopic and open approach. 11 (79.6%) patients had invasive disease, three (21.4%) had noninvasive disease. Eight (57.1%) patients subsequently developed recurrence and required multiple surgical debridements. The mean number of debridements was 1.5. Median time to second surgery was 11 days. Six (42.9%) patients died during their postoperative recovery. One mortality was due to massive epistaxis leading to hypovolemic shock. The remaining eight (57.1%) patients were discharged postsurgery. Median time to discharge was 23 days.

Conclusion: Acute fungal rhinosinusitis is a rare complication of immunocompromised patients. Surgical intervention is an option for definitive management; however, postoperative mortality and risk of recurrence requiring additional surgical interventions remains high. Patients with diabetes had a better prognosis than those with a hematological malignancy. Due to the long delay of obtaining positive fungal cultures and pathology, we advocate early aggressive multimodal treatment. Multiple debridements may be necessary in most cases and close surveillance is needed during treatment.