Frozen Section as a Rapid and Accurate Method for Diagnosing Acute Invasive Fungal Rhinosinusitis

Abstract

Objective Identify methods to improve the frozen-section diagnosis of acute invasive fungal rhinosinusitis. Study Design Biopsies with frozen section for suspected acute invasive fungal rhinosinusitis were reviewed to identify causes for missed diagnoses and evaluate methods for potential improvement. Setting All aspects of the study were performed at the Penn State Milton S. Hershey Medical Center. Subjects and Methods All frozen sections performed for suspected acute invasive fungal rhinosinusitis between 2006 through 2017 were reviewed with their diagnoses compared to the final diagnoses. Sensitivity and specificity were determined for each biopsy specimen to evaluate the diagnostic method and for each patient for its effectiveness on outcome. Causes for frozen-section failures in diagnosis were identified. A periodic acid-Schiff stain for fungus (PASF) was modified for use on frozen tissue (PASF-fs) and applied both retrospectively and prospectively to frozen sections to determine its ability to identify undetected fungus and improve diagnostic sensitivity. Results Of 63 biopsies positive for acute invasive fungal rhinosinusitis, 51 were diagnosed on frozen section, while 61 were identified by including the novel PASF-fs stain, reducing the failure rate from 19% to 3%. Of 41 cases that were positive, 34 were diagnosed on frozen section. Of the 7 that were not, 5 were identified by including the PASF-fs, reducing the failure rate from 17% to 5%. Conclusions Frozen section interpretation of biopsies for suspected acute invasive fungal rhinosinusitis using a PASF-fs stain should enable a rapid and accurate diagnosis with improved outcomes by shortening the time to surgery.

Retrospective Analysis of Patients With Acute Invasive Fungal Rhinosinusitis in a Single Tertiary Academic Medical Center: A 10-Year Experience

“…This life-threatening infection advances quickly and has the potential to spread to involve the orbit as well as intracranial tissues. 1 While most often found in those with diabetes and hematologic malignancies, including bone marrow transplant recipients, AIFRS is also found in other immunocompromised populations, including patients with acquired immunodeficiency syndrome, solid organ transplants, iron overload, protein-energy malnutrition, or those on prolonged courses of steroids. [1][2][3] Presenting symptoms are often nonspecific but may include sudden onset of facial pain, fever, epistaxis, and nasal congestion.…”

“…1 While most often found in those with diabetes and hematologic malignancies, including bone marrow transplant recipients, AIFRS is also found in other immunocompromised populations, including patients with acquired immunodeficiency syndrome, solid organ transplants, iron overload, protein-energy malnutrition, or those on prolonged courses of steroids. [1][2][3] Presenting symptoms are often nonspecific but may include sudden onset of facial pain, fever, epistaxis, and nasal congestion. 3,4 Outcomes in patients with AIFRS are variable but uniformly unfavorable, with mortality noted in the literature as high as 50% to 80%.…”

Acute Invasive Fungal Rhinosinusitis: Frozen Section Histomorphology and Diagnosis with PAS Stain

“…The effect of delay in DX resulted in an adverse outcome in our patients with false negative diagnoses. Surgical treatment in 6 was delayed from 24 to 48 h with more extensive debridement required, and the potential to prevent death was lost in one where necrosis progressed extensively into the orbit and surrounding tissues [16]. Added to any delay in DX is the process of preparation for surgery with these patients frequently needing platelet and sometimes red cell transfusions.…”

Rinosinusitis fúngica invasiva aguda: Actualización en pacientes adultos y pediátricos

“…Las tinciones de plata y PAS pueden ayudar a evidenciar formas fúngicas en paredes y lúmenes vasculares 18 . Este examen se debería realizar ante cualquier anormalidad presente en la evaluación endoscópica, sin embargo, se ha planteado la toma de biopsias en pacientes con factores de riesgo y sospecha alta incluso con tejidos aparentemente normales 19 . Se ha sugerido la biopsia de cornete medio, considerando que es el lugar más frecuentemente reportado, alcanzando una sensibilidad de 75% a 86% y especificidad de 100% 5,8,19 .…”

“…El uso de esta tinción permitió aumentar la sensibilidad de los análisis de sección congelada desde 85,4% al 95,2%, registrándose además una especificidad de 100%. Este resultado si bien es alentador, no resultó ser estadísticamente significativo, lo que podría ser explicado por el pequeño tamaño muestral del estudio 19 .…”