Non-Exenteration Management of Sino-Orbital Fungal Disease

Athavale, Dnyaneshwar D.; Jones, Robin; O’Donnell, Brett A; Forer, Martin; Biggs, Nigel

doi:10.1097/iop.0000000000000812

Cited by 15 publications

(12 citation statements)

References 24 publications

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“…We believe the role of exenteration in the management of orbital mycoses, particularly mucormycosis, is to debride and remove extensively involved necrotic, non-viable orbital tissue, acknowledging that it has not been shown to improve survival in this series. Where there is minimal orbital involvement, as in the cases described by Athavale et al, [ 10 ] we agree that non-exenteration management is appropriate.…”

Section: Discussionsupporting

confidence: 71%

“…The routine administration of amphotericin B particularly in its liposomal form has been found to reduce mortality in mucormycosis [ 4 , 5 ]. Some authors advocate aggressive surgical debridement with orbital exenteration for mucormycosis [ 9 ], whereas others have demonstrated survival with a more conservative approach without exenteration [ 10 ]. Nonetheless there remains a lack of consensus regarding the indications for exenteration, with the decision to perform this procedure resting primarily on the judgement of the treating physicians [ 11 ].…”

Section: Introductionmentioning

confidence: 99%

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Orbital mycoses in an adult subtropical population

Lee

Allworth

et al. 2019

Eye

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Background/objectives To report the spectrum of fungal infections involving the orbit encountered in an Australian subtropical population with respect to presentation, host risk factors, involved pathogens, treatment and outcomes. Subjects/methods A retrospective chart review was performed on all adult patients with orbital mycosis treated by the senior author (TJS) from 1986 to 2017 in a tertiary setting. Results Thirty cases of fungal infection involving the orbit were included in this case series. Of these, 26 patients had invasive disease and four patients had non-invasive disease. Causative organisms included mucormycosis (16), aspergillus (8) and other fungi (7). Common risk factors included haematological disorders or malignancy, neutropenia, corticosteroid use and diabetes mellitus. Mucormycosis in three immunocompetent patients was caused by Apophysomyces elegans . Orbital apex syndrome was observed in approximately one third of patients at initial ophthalmological assessment. Amphotericin B was used in most cases of mucormycosis, while there was a more varied spectrum of anti-fungal use in other fungal infections. Seven patients with mucormycosis proceeded to orbital exenteration with a survival rate of 43%. No patients with other orbital fungal infections were exenterated. Conclusions Orbital mycoses are not only opportunistic but true pathogenic infections. While initial symptoms may be varied, the development of orbital apex syndrome should raise suspicion for this condition, regardless of patient immune status or age. Survival and visual outcomes are often poor with invasive disease. Multidisciplinary team management with early orbital specialist involvement is essential.

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Section: Discussionsupporting

confidence: 71%

Section: Introductionmentioning

confidence: 99%

Orbital mycoses in an adult subtropical population

Lee

Allworth

et al. 2019

Eye

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“…Many authors have discussed mortality rates and exenteration, with Hirabayashi et al finding no differences in the mortality rate between subjects who either did or did not have their orbit exenterated [ 20 ]. Besides, Athavale et al reported consecutive 6 patients with sino-orbital fungal disease preferably be treated conservatively, without orbital exenteration [ 21 ]. Trief et al have suggested that exenteration should be considered for individual patients [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

Acute Invasive Fungal Rhinosinusitis-Related Orbital Infection: A Single Medical Center Experience

Huang

Liang

et al. 2021

Journal of Ophthalmology

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Backgrounds. Acute invasive fungal rhinosinusitis (AIFRS) is a hazardous infectious disease with rapid progression and high mortality and morbidities. Further orbital involvement is commonly seen. This study aims to analyze risk factors, clinical characteristics, and outcomes between patients with or without orbital involvement. Methods. A retrospective review was performed in a single tertiary medical center over a span of 13 years (2005–2018). A total of 21 patients with diagnosis of AIFRS were enrolled. We reviewed the patients’ basic characteristics, comorbidities, clinical presentations, image study findings, culture pathogens, and treatment outcomes and analyzed the differences between orbital-involved and orbital sparing disease. Results. The most common comorbidities in AIFRS were diabetes mellitus (DM) and hematological malignancy. Nine the 21 AIFRS patients had orbital-involved disease. Patients with orbital involvement had a higher prevalence of DM ( p < 0.05 ). Image studies revealed significant infection of the ethmoid sinus, sphenoid sinus, and frontal sinus in the group with orbital complication ( p < 0.05 ). Mucor, Rhizopus, and Aspergillus were cultured in both groups. Five patients in the orbital involvement group expired, with all of them having an initial presentation of conscious disturbance ( p < 0.01 ). Rhino-orbital-cerebral fungal infection was noticed in 3 of the 5 expired patients. Conclusion. In AIFRS patients, DM other than hematological malignancy was the main risk factor for orbital-involved disease. Patients with ethmoid, sphenoid, or frontal sinusitis had a higher possibility of orbital complication. Poor consciousness at initial presentation revealed highest possibility of rhino-orbital-cerebral fungal infection and led to death.

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“…Some retrospective studies have indicated that orbital exenteration may not be necessary as early conservative management may be adequate. 35 Other studies aimed to determine evidence based-standards regarding exenteration. 36,37 In such a prospective analytical study, a scoring system was proposed based on clinical signs and symptoms, direct and indirect ophthalmoscopy, and imaging.…”

Section: Discussionmentioning

confidence: 99%

A systematic review of orbital apex syndrome of odontogenic origin: Proposed algorithm for treatment

Leferman

Ciubotaru

Ghiciuc

et al. 2020

European Journal of Ophthalmology

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Orbital apex syndrome (OAS) can be a rare, but severe complication of an odontogenic infection and has high morbidity and mortality. Antibacterial drugs are typically an appropriate treatment choice, but the most severe cases are fungal in nature and pose a tough challenge to the clinician. The aim of this study was to determine the predisposing factors, specific aspects in its management and the appropriate treatment strategy in order to improve patient outcome. A systematic review was conducted using PubMed, PubMed Central, Web of Science, and Scopus up to February 2020, based on the associations between dental extraction or infections and OAS. Of 721 papers found, 18 articles were considered eligible and presented in total 21 cases (13 fungal and eight bacterial infections). The information was organized into a diagnostic and treatment algorithm which included data extracted both from the included cases and updated literature of treatment efficacy studies. Immunosuppression (uncontrolled diabetes mellitus and chemotherapy) was found as an important predisposing factor particularly for fungal infections. In these cases, we suggest that early simultaneous approaches, including aggressive surgical procedures and systemic administration of amphotericin B, result in a better outcome. In conclusion, medical intervention success depends on aggressive treatment and multidisciplinary teamwork.

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Non-Exenteration Management of Sino-Orbital Fungal Disease

Abstract: The authors recommend that patients with sino-orbital fungal disease preferably be treated conservatively, without orbital exenteration.

Cited by 15 publications

References 24 publications

Orbital mycoses in an adult subtropical population

Orbital mycoses in an adult subtropical population

Acute Invasive Fungal Rhinosinusitis-Related Orbital Infection: A Single Medical Center Experience

A systematic review of orbital apex syndrome of odontogenic origin: Proposed algorithm for treatment

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