Fungal sinusitis with intracranial extension in immuno-competent patients: surgical planning according to relation to eloquent neurovascular structures

ABSTRACT

To evaluate the results of combined neurosurgical and ENT surgical management for patients with fungal sinusitis with intracranial extension. We managed 10 cases with fungal sinusitis with intracranial extension. This included 7 females and 3 males. Four patients presented with unilateral proptosis, 2 with deterioration of level of consciousness due to meningitis, 2 with chronic headache, one with epilepsy and one patient presented with trigeminal pain. All cases had long history of chronic headache and nasal obstruction. CT was done in all cases, MR in 8 patients, CT angiography and conventional cerebral angiography in one patient. Surgical intervention was decided according to the relation of the fungal granuloma to eloquent intracranial structures. Endonasal approach alone was used when the granuloma was not related to the optic nerve, internal carotid artery or cavernous sinus [n=3]. Combined subfrontal and endonasal approach was used when the granuloma was closely related to one or more of these structures [n=5]. Transcranial approach alone was done for 2 patients with isolated sphenoid fungal sinusitis that was associated with a mycotic internal carotid artery aneurysm in one patient and with a temporal lobe abscess in the other. In addition, antifungal treatment was used for 8-12 weeks. Patients were followed up clinically and radiologically for 6-36 month period. No morbidity related to the operative procedures was recorded in the study group. One patient died two month post-operatively due to fungal meningitis. In survivors [n=9] headache and nasal obstruction improved, proptosis was corrected, epilepsy and trigeminal pain were controlled by medication. Follow-up CT showed eradication of the fungal granuloma in all survivors. Histopathological results showed mucormycosis [n=2], aspirgillosis [n=4], and no fungus [4 patients. Team work by ENT and neurosurgical staff and early diagnosis are mandatory in the management of fungal sinusitis with intracranial extension in immune-competent patients. Surgical planning according to the relation of fungal granuloma to eloquent neurovascular structures is the cornerstone for save removal of granuloma