xRead - Nasal Obstruction (September 2024) Full Articles

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654

International consensus statement on rhinosinusitis

clinical context is essential. 2417,2427 Most cases of AIFS demonstrate some degree of mucoperiosteal thickening within the nasal cavity (early) or paranasal sinuses on CT, often unilateral. 2428,2429 MRI can be used adjunctively to assess extent of disease particularly when there is bone ero sion and orbital or intracranial involvement is suspected. Nasal endoscopy is critical, and early findings may be sub tle, such as edema with violaceous or pale mucosa and lack of sensation, with subsequent progression to eschar and necrosis due to ischemia and vascular thrombosis. Rapid diagnosis is critical. Diagnosis is established with biopsy of suspected tissue, with the middle turbinate often a high-yield location. 2430 Some experts have advocated for the use of frozen section in order to speed the diag nosis even further, with 1 study demonstrating improved survival rates in immunocompromised patients with pre sumed AIFS. 2431 The mainstays of treatment for AIFS are (1) timely sur gical debridement, (2) initiation of intravenous antifun gal therapy, and (3) reversal of the underlying immun odeficiency. Effective multidisciplinary care for patients with AIFS is paramount and should include a clear under standing of the goals of care. As demonstrated by several studies, sinus surgery improves survival in patients with AIFS. 2417,2428,2432 Turner et al. reported odds of mortal ity were increased in patients with intracranial involve ment (OR: 1.892) and decreased in patients undergo ing either endoscopic or open surgery (OR: 0.357, 0.486, respectively). 2417 The survival benefit from surgery may be attributable to prompt diagnosis, which may also have benefit in decreasing long-term morbidity, 2433 col lection of cultures, removal of the fungal burden, and enhanced postoperative endoscopic surveillance; however, selection bias of patients able to tolerate surgery must be considered. Antifungal therapy should be initiated immediately if the clinical suspicion for AIFS is high as delay has been linked to decreased survival. 2434 In the treatment of Aspergillus, IV and oral azole agents (eg, voriconazole, isavuconazole) are the first-line therapy, 2435,2436 whereas IV liposomal amphotericin remains the treatment of choice for Zygomycetes infections. 2417,2434 Isavuconzole or posaconazole, which are available orally, may also be effective in treating Zygomycetes with potentially fewer side effects, 2437 however, additional evidence is needed to support their first-line use. Additionally, posaconazole as primary prophylaxis in high-risk populations (eg, graft versus-host-disease, acute myeloid leukemia, myelodys plastic syndrome) has been studied, however, their poten tial benefit must be weighed against risk of toxicities and selection for resistant infections. 2438

Multi-institutional studies and systematic reviews in adults 2417 and children 2418 represent the best evidence for AIFS. Studies of CIFS and GIFS are much more limited but recent multi-institutional studies have provided important insights into these rarer variants.

XIV.D.1

Acute Invasive Fungal

Rhinosinusitis (AIFS) AIFS is the most common 2419 and life-threatening form of IFS, with a mortality rate of 50% to 80% in affected adults and children, 2417,2418,2420,2421 although disease-specific mortality may be lower. 2422 Nearly all patients with AIFS are immunosuppressed. In adults, poorly controlled DM is the prevailing comorbidity (47.8%), followed by hematologic disorders (39.8%); 2417 whereas, hematologic disorders accounted for 81.5% of cases in children. 2418 The 2 most prevalent organisms responsible for AIFS are from the Aspergillus genus and from the Zygomycetes order, including Mucor, Rhizopus, and Rhinomucor . 2423,2424 Aspergillus is prevalent in the envi ronment and becomes invasive when host immune defenses are compromised. 2414 Zygomycetes demonstrates a predilection for diabetic patients due to its affinity for acidotic and high glucose environments. 2414 Fusarium , Scedosporium , Pseudoallescherii boydi, and dematiaceous fungi may also cause AIFS, however these organisms are much less common. While variety exists in the offending organisms, their differential effect on survival outcome in AIFS remains unclear. 2417,2425 The risk of mortality varies by underlying immuno logic impairment. In a systematic review of 52 studies and over 800 patients, odds of mortality in AIFS was about half in patients with DM (OR: 0.492) compared to others. 2417 Similarly, in a population-based study of 979 patients who underwent surgery for AIFS, the odds of mor tality in patients with DM were also significantly lower (OR: 0.53). 2426 The lower mortality risk is attributed to the reversible nature of hyperglycemia in DM, as compared to the less reversible state of neutropenia in hematologic dis orders. Encouragingly, a recent multi-institutional study of 114 patients demonstrated decreased mortality in patients with hematologic disorders after initiation of granulocyte stimulation factor. 2423 While this shows promise for these patients, the practicality and long-term effects warrant fur ther investigation. The most common symptoms of AIFS are nonspecific and include facial swelling (64.5%), fever (62.9%), and nasal congestion (52.2%). 2417 As such, increased clinical suspicion and prompt diagnostic testing in the appropriate