Role of Middle Turbinate Biopsy in the Diagnosis of Fulminant Invasive Fungal Rhinosinusitis

Abstract

Middle turbinate biopsy is a safe and effective method of making a timely diagnosis of fulminant invasive fungal rhinosinusitis. The added morbidity and cost of surgery can be avoided in the patient with a negative finding on biopsy. However, the effect of earlier diagnosis on overall patient survival is unclear at present.

Nasal Eschar

“…It is safe, straightforward, rapid, and has a low rate of complications. 7 Management of IFS includes surgical debridement and systemic antifungal treatment as performed on G.H. Surgical debridement is needed to reduce the fungal load, slow the progression of disease, remove necrotic tissue, and provide tissue for biopsy.…”

Managing acute invasive fungal sinusitis

“…Perform nasal endoscopy to inspect the nasal mucosa for insensate areas, ulcers, pale nasal mucosa that may represent ischemia, and the presence of eschar (which is pathognomonic for acute invasive fungal sinusitis). 12 Nasal mucosa may appear edematous and hypervascular secondary to acute infl ammation. Alternately, it may appear pale and have minimal bleeding when biopsied due to ischemia.…”

“…This may be why the middle turbinate is the most frequently positive biopsy site, accounting for two-thirds of the cases. 12 The otolaryngologist will take additional biopsies of any areas appearing to have ischemia, necrosis, eschar, or sloughing of tissues within the nasal or oral cavity.…”

“…7 Tissue biopsy is critical not only in establishing a diagnosis but in directing appropriate therapy. 5,12,14 Nasal endoscopy may not provide adequate visualization and imaging studies are a necessary supplementation. Imaging also plays an integral role in establishing the diagnosis, evaluating the extent of the disease, and guiding surgical planning for further biopsy and debridement.…”

“…17 Patients suffering from acute invasive fungal sinusitis with orbital complications may have CT fi ndings of sinus wall erosions and hyperdense lesions. 12 CT characteristics include unilateral opacifi cation of multiple sinuses, often with focal bone erosion, soft-tissue thickening, and edema of the sinuses and lateral nasal wall mucosa, subtle infi ltration of premaxillary fat, and orbital invasion. 5,18 Involvement of the ethmoid or sphenoid sinuses and bony destruction are negative prognostic factors and increase the likelihood of extension to surrounding structures.…”