Intracranial complications of sinusitis: what is the role of endoscopic sinus surgery in the acute setting.

OBJECTIVE: Intracranial complications of sinusitis (ICS) are uncommon in the antibiotic era. The role of neurosurgical drainage of ICS is fairly well established, but the role for acute surgical intervention for the sinus disease is not well defined. We retrospectively reviewed our experience with ICS to see if we could identify the role and effectiveness of endoscopic sinus surgery (ESS) in the acute setting of ICS. METHODS: The study used a retrospective review of patients presenting to a tertiary care academic medical center for a 6-year period. RESULTS: Twenty-three patients were identified with ICS, including epidural (8), subdural (10), intracerebral abscesses (2), and meningitis (3). Males were more affected than females (7:1). Twenty patients were 21 years old or younger. Twenty-two patients (96%) had radiologic evidence of frontal sinusitis with prefrontal or frontal lobe ICS at presentation. Medical therapy alone was successful in avoiding craniotomy in only 3 of 8 cases. Endoscopic sinus surgery and intravenous antibiotics as initial treatment was successful in avoiding craniotomy in only 1 of 6 patients. Of 23 patients, 18 underwent neurosurgical procedures--9 emergent procedures for abscesses more than 1 cm and 9 delayed procedures for persistent disease despite ICS less than 1 cm at presentation. CONCLUSIONS: Intracranial complications of sinusitis usually result from indirect spread of acute frontal sinusitis. The role of ESS in the initial treatment of ICS is not clear. In our series, ESS did not appear to alter the need for neurosurgical intervention, which was ultimately necessary in most patients with ICS, even with lesions less than 1 cm.

Orbital and cranial nerve presentations and sequelae are hallmarks of invasive fungal sinusitis caused by Mucor in contrast to Aspergillus.

BACKGROUND: Acute fulminant invasive fungal sinusitis (IFS) is a rapidly progressing, destructive process almost exclusively affecting immunocompromised patients. Outcome differences have been found in patients with Mucor and Aspergillus. We performed this study to compare the presenting symptoms and long-term morbidity with IFS caused by Mucor versus Aspergillus species. METHODS: Retrospective chart review was performed of 48 patients with 49 cases of acute fulminant IFS over a 19-year period. Presenting symptoms and long-term morbidity related to the orbits and cranial nerves were evaluated. RESULTS: Mucor was found in 22 cases and Aspergillus was found in 27 cases. Orbital (proptosis, periorbital edema, and ophthalmoplegia) and cranial nerve symptoms were seen at presentation more often in Mucor (6 [27%] and 9 [41%]) than in Aspergillus patients (3 [11%] and 7 [26%]; p=0.079). Long-term orbital and cranial nerve sequelae occurred in 16 (72%) Mucor cases and 10 (37%) Aspergillus cases (p=0.0210). The IFS-related mortality was 32% (7) in the Mucor group and 11% (3) in the Aspergillus group (p=0.089). CONCLUSION: Patients with acute fulminant IFS present with similar sinus symptoms; however, there is a trend toward a greater prevalence of orbital and neurological symptoms in patients with Mucor versus Aspergillus. Long-term orbital and neurological morbidity is more prevalent in patients with Mucor compared with Aspergillus. These data suggest that the presence of orbital and neurological symptoms at presentation warrants more aggressive surgical intervention because of the likelihood of Mucor.

Inverted papilloma of the nasolacrimal system invading the orbit.

A 73-year-old man with a history of epiphora, discharge from the left eye, and left-sided nasal congestion underwent external dacryocystorhinostomy for nasolacrimal duct obstruction. The procedure revealed bony erosion of the majority of the lacrimal sac fossa and a large papillomatous mass filling the lacrimal sac and nasolacrimal duct. Inverted papilloma was diagnosed via biopsy. A subsequent orbitotomy with combined endoscopic medial maxillectomy was performed to remove the mass. This case illustrates the importance of including inverted papilloma, a benign but invasive neoplasm, in the differential diagnosis of nasolacrimal duct obstruction.

Invasive fungal sinusitis: a 15-year review from a single institution.

BACKGROUND: The aim of this study was to review our experience with patients with invasive fungal sinusitis (IFS) to determine outcomes and identify factors that may affect patient survival. METHODS: A retrospective review was performed. RESULTS: Forty-three patients were identified accounting for 45 cases of IFS. The underlying reasons for immunosuppression were hematologic malignancy (28 patients), diabetes mellitus (10 patients), solid organ transplant (3 patients), chronic steroid use (3 patients), and acquired immunodeficiency syndrome (1 patient). Eight of 45 cases (18%) died of IFS. Of the 28 cases associated with hematologic malignanancy, 3 patients died of IFS (11%) and 4 patients (14%) died of other causes with persistent IFS. None of these 7 patients had recovery of their absolute neutrophil count, and all patients who recovered from IFS recovered to a normal absolute neutrophil count. Four of 10 (40%) diabetic patients died of IFS, and 66% of survivors had persistent neurological or visual morbidity. The imortality rate was 29% for patients infected with Mucor and 11% for patients injected with Aspergillus. CONCLUSION: We have found the overall mortality rate directly related to IFS to be 18%. The rate is higher for diabetic patients than for patients with hematologic causes for their immunosuppression. This is likely because of the higher index of suspicion and early diagnosis and treatment of patients with neutropenia and a less-fulminant, slower-progressing form of IFS from Aspergillus, apparently a less virulent fungus than Mucor. Intracranial involvement and failure to recover from neutropenia are the factors that led to poor prognosis in this series.