Invasive sino-orbital aspergillosis: surgical decisions and dilemmas

Abstract

Invasive aspergillosis, one of the common paranasal sinus fungal infections, often secondarily involves the orbit. We report six such cases with orbital extension, all occurring in apparently immunocompetent hosts, to specifically address the difficult diagnostic and therapeutic issues involved. Limited biopsy procedures were often inconclusive, necessitating wide surgical excision to establish the histopathological diagnosis. Conservative orbital debridement proved adequate for cases with disease limited to the infero-medial compartment of the orbit, but resulted in residual progressive disease in the two of the four cases with retro-orbital and apical extension. Orbital exenteration in this latter group, however, proved successful in controlling disease. The present report emphasizes the importance of near-complete extirpation and adjuvant chemotherapy in ensuring a favourable outcome in invasive Aspergillus infections. Orbital exenteration appears justified for posterior orbital disease, regardless of the functional status of the eye, but is inappropriate for anterior orbital disease.

Invasive Sphenoidal Aspergillosis: Successful Treatment with Sphenoidotomy and Voriconazole

“…Diagnosis can be suspected by the clinical aspect during surgery but needs confirmation by histology and microbiological methods, the results of which are available after 3-4 days. Cultures can be falsely negative in 40-50% of the cases (in our case series 75%) [1,18] and histopathological confirmation can be difficult when only necrotic tissue is obtained in biopsies [17] , as observed in other cases not part of this study. However, histopathology is evident to confirm or exclude an invasive fungal process, as well as to differentiate from other pathologies with radiological bone erosions as seen, e.g., in an allergic fungal rhinosinusitis [19] .…”

“…However, histopathology is evident to confirm or exclude an invasive fungal process, as well as to differentiate from other pathologies with radiological bone erosions as seen, e.g., in an allergic fungal rhinosinusitis [19] . But even in negative biopsies, the possibility of an invasive mycosis must be kept in mind in patients with an erosive and destructive mass involving the cavernous sinus or the orbital apex [1,17] with a rapid decision of an antifungal treatment due to its high mortality. Amphotericin B, not being available for oral application, is associated with a high rate of nephrotoxicity (as seen in patients 1 and 2) and infusion reactions.…”

Invasive Fungal Infections of the Orbit

“…32 The chronicity of the disease along with a lack of acute signs or symptoms often masks the deadly nature of the infection and can delay diagnosis for months to years. Infections in healthy patients typically occur in specific geographic areas with warm, tropical, or desert climates such as the Middle East, Indian sub-continent, Southern United States 32 and Sudan.…”

“…Care should be taken to biopsy a sufficient amount of tissue, because many authors have reported a high rate of negative or inconclusive results. 32 Often, if suspicion for fungal infection is high, repeat biopsies are necessary.…”

“…With widespread orbital involvement, exenteration may be necessary to maximize the chance of achieving clean surgical margins. Dhiwakar et al 32 have reported that in immunocompetent patients a low threshold for exenteration is necessary when infection involves the orbital apex, regardless of the functional status of the eye. The close proximity of the apex to the brain provides multiple routes for intracerebral spread of infection, such as the optic nerve, ophthalmic artery, and superior orbital fissure.…”