2019 Volume 58 Issue 2 Pages 209-219
A 67-year-old diabetic male who presented with a two-month history of double vision and impaired visual acuity was referred to Nara Prefectural General Medical Center. Computed tomography showed a lesion within the left maxillary, ethmoid, and sphenoid sinuses and pterygoid fossa, which exhibited left orbital and intracranial invasion. On the 8th day after the first medical examination at our hospital, endoscopic sinus surgery (ESS) was performed, and a diagnosis of invasive fungal sinusitis with aspergillosis was made. We systemically administered the antifungal agent voriconazole (VRCZ) and treated the patient’s diabetes mellitus with insulin. The patient completely recovered without any visual acuity or ocular movement sequelae.
We reviewed the 37 cases of invasive fungal sinusitis reported from 2010 to 2018 in Japan including this case. In 28 cases (75.7%), the lesion extended to either the posterior ethmoid or sphenoid sinuses. Eighteen cases (48.6%) were accompanied by diabetes mellitus. In most cases, aspergillus was identified. Visual disturbance, restricted ocular movement, intraorbital invasion, and intracranial invasion were seen in 26 (70.3%), 21 (56.8%), 28 (75.7%), and 17 (45.9%) of the cases, respectively. The antifungal agent VRCZ was systemically administered in 33 (89.2%) of the cases. ESS, the Caldwell-Luc operation, and extensive surgery were performed in 32 (86.5%), 2 (5.4%), and 3 (8.1%) of the cases, respectively. The overall mortality rate was 19.9%, which was much lower than that in previously reported series.
Univariate regression analysis demonstrated statistically significant associations between mortality and diabetes mellitus (p = 0.037) or between mortality and intracranial invasion (p = 0.026). Multiple regression analysis was used to identify predictors of mortality. This analysis included diabetes mellitus, intracranial invasion, and visual disturbance. Only intracranial invasion was found to be significantly related to mortality (p = 0.047) as a predictor of mortality by multiple regression analysis.
Patients that experienced visual loss before treatment showed no post-treatment improvement in their visual acuity. Among the cases involving pre-treatment visual acuity of >0.01, visual acuity improved in 5 out of 6 of the patients (83.3%) after treatment. Ocular movement improved after treatment in 13 out of 17 of the patients (76.5%).
Prompt diagnosis via ESS and treatment with VRCZ are essential for treating invasive fungal sinusitis without sequelae.
