Fungal sinusitis is categorized into invasive and non-invasive. Non-invasive fungal sinusitis generally carries a favorable prognosis, while invasive fungal sinusitis carries a poor prognosis and could prove fatal if it spreads intracranially.
We report two patients with invasive fungal sinusitis that invaded the skull base, who were treated by endoscopic sinus surgery (ESS) and voriconazole.
Case 1: The patient was a 78-year-old diabetic man who presented with the chief complaints of severe headache and vomiting, but no ocular symptoms. Magnetic resonance imaging (MRI) revealed mycosis of the right maxillary sinus and pachymeningitis. ESS was performed twice for residual lesions and voriconazole was administered for 12 months. No recurrence has been observed for 44 months since the diagnosis.
Case 2: The patient was a 74-year-old man who presented with the chief complaint of postnasal discharge, and computed tomography (CT) revealed findings of sphenoiditis and a bone defect in the skull base. ESS was performed, but it was thought that the lesion could not be opened sufficiently, due to hyperostosis and lack of a proper navigation system. A second ESS was scheduled, but while waiting for the surgery, he presented with oculomotor nerve palsy of gradual onset, resulting from intracranial invasion of the mycosis. After the second ESS and voriconazole administration for 7 months, no recurrence has appeared for 29 months.
Both cases were treated with ESS and voriconazole. The symptoms resolved, and there has been no recurrence. The first patient presented without ocular symptoms, which is atypical for invasive fungal sinusitis. In the second patient, it became difficult to determine when to perform the second ESS, because we could not definitively diagnose the presence of residual inflammation/invasion.
In immunocompromised patients diagnosed as having fungal sinusitis, prompt surgery and medical treatment are important, even if invasion by the fungus cannot be confirmed, given that it can be difficult to distinguish between invasive or non-invasive fungal sinusitis.
