An internally validated diagnostic tool for acute invasive fungal sinusitis

Abstract

BackgroundAcute invasive fungal sinusitis (AIFS) is a potentially life‐threatening diagnosis in immunocompromised patients. Identifying patients who could benefit from evaluation and intervention can be challenging for referring providers and otolaryngologists alike. We aimed to develop and validate an accessible diagnostic tool to estimate the probability of AIFS.MethodsRetrospective chart review from 1999 to 2017 identified all patients evaluated for possible AIFS at a tertiary care center. AIFS was diagnosed by pathologic confirmation of fungal tissue angioinvasion. Stepwise selection and univariate logistic regression were used to screen risk factors for a multivariable predictive model. Model performance was assessed using Tukey's goodness‐of‐fit test and the area under the receiver operator characteristic curve (AUC). Model coefficients were internally validated using bootstrapping with 1000 iterations.ResultsA total of 283 patients (244 negative controls, 39 with AIFS) were included. Risk factors in our final diagnostic model included: fever ≥38°C (log‐odds ratio [LOR] 1.72; 95% CI, 0.53 to 2.90), unilateral facial swelling, pain, or erythema (LOR 2.84; 95% CI, 1.46 to 4.23), involvement of the orbit or pterygopalatine fossa on imaging (LOR 3.02; 95% CI, 1.78 to 4.26), and mucosal necrosis seen on endoscopy (LOR 5.52; 95% CI, 3.81 to 7.24), with p < 0.01 for all factors. The model had adequate goodness of fit (p > 0.05) and discrimination (AUC = 0.96).ConclusionWe present an internally validated diagnostic tool to stratify the risk for AIFS. The estimated risk may help determine which patients can be observed with serial nasal endoscopy, which ones could be biopsied, and which ones would benefit from immediate surgical intervention.

Post-COVID-19 acute invasive fungal rhinosinusitis: a systematic radiological approach in the light of clinico-surgical characteristics

“…This is discordant with Turner et al [ 14 ], who described external debridement for 37.2%, endoscopic debridement in 37% and combined open and endoscopic debridement for 24.1% and Malleshappa et al [ 16 ] who recorded partial/total maxillectomy (29.4%), orbital exenteration (7.8%) and craniotomy (2%), while Allensworth et al [ 18 ] found that ten patients underwent maxillectomy, six with orbital exenteration. In concordance with a study done by Yin et al [ 15 ], most patients were treated with a combination of intravenous antifungal medication and surgery. Two patients passed away before surgery.…”

“…Extension into the orbit results in proptosis, deterioration in vision or even visual loss (70.4%), facial skin infarction, and ulceration in 46.3%. In addition, Yin et al [ 15 ] described that unilateral facial swelling, pain, or erythema were the most common presentations, involvement of the orbit or pterygopalatine fossa on imaging, and mucosal necrosis is seen on endoscopy.…”

“…Extension into the orbit results in proptosis, deterioration in vision or even visual loss (70.4%), facial skin infarction, and ulceration in 46.3%. In addition, Yin et al [15] described that unilateral facial swelling, pain, or erythema were the most common presentations, involvement of the orbit or pterygopalatine fossa on imaging, and mucosal necrosis is seen on endoscopy. As expected, the most commonly associated predisposing conditions were diabetes mellitus in concordance with the study of Malleshappa et al [16] found that 78.4% patients were diabetic in concordance with the study of Wandell et al [17] aggressive infection occurring in immunocompromised patients.…”

Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence‐Based Review with Recommendations

“…Abnormalities suggestive of AIFS have included mucosal edema, discoloration (e.g., pallor or darkened tissue), ulceration, and lack of sensation. In general, select nasal endoscopy findings for AIFS are considered highly specific, but have a wide range in reported sensitivity, ranging from 49% to 75% 7,19,38,58,63,85,86 …”

Magnetic Resonance Imaging Prognostic Findings for Visual and Mortality Outcomes in Acute Invasive Fungal Rhinosinusitis

“…Other studies have developed diagnostic tools and based treatment protocols on CT imaging; however, early CT findings may be nondescript and may overlap with other entities. 9,43,44 In contrast, MRI provides greater sensitivity given the critical need to establish the diagnosis and to initiate prompt therapy. 10,13 Based on the present findings, initial MRI can be used to anticipate outcomes and potentially to assist in establishing care goals with the patient and family.…”