Department of Ophthalmology, University of California, San Francisco, San Francisco, California, U.S.A.
Department of Ophthalmology, University of Montreal, Montreal, Quebec, Canada.
Ophthalmic Plast Reconstr Surg. 2019 Nov/Dec;35(6):535-542. doi: 10.1097/IOP.0000000000001357.
Invasive fungal sinusitis is a rare but potentially lethal disease that primarily affects immunocompromised patients. The purpose of this study was to review an academic medical center's experience in the presentation, diagnosis, and treatment of invasive fungal sinusitis.
A retrospective chart review was performed at a single institution over a 17-year period. Medical records, radiographic imaging, and operative reports were analyzed. Bivariate and multivariable analyses were performed to determine factors that affected visual acuity outcomes and mortality.
Fifty-five patients with histopathologically confirmed invasive fungal sinusitis were included. The average duration of follow up was 1.8 ± 2.6 years (range: 1 week to 10 years). The most common causes of immunosuppression were hematologic malignancy (45%), diabetes (31%), and organ transplantation (9%). At presentation, 35% of individuals were neutropenic (absolute neutrophil count < 500/μl). All patients received systemic antifungal treatment. A surgical intervention was performed on 50 patients (91%), and all but one had functional endoscopic sinus surgery. Nine (16%) patients underwent orbital exenteration. Multivariable analysis of visual acuity outcomes demonstrated that individuals infected with Zygomycota had 6-7 lines worse vision than those infected with Ascomycota (mean difference in logMAR 0.66, 95% confidence interval 0.27 to 1.06, p = 0.001). Patients who had functional endoscopic sinus surgery had 7-8 lines better visual acuity than those without functional endoscopic sinus surgery (mean difference in logMAR -0.76, 95% confidence interval -1.13 to -0.38, p < 0.001). The overall death rate due to infection was 24%. Bivariate models demonstrated no difference in mortality in patients receiving exenteration versus those who did not (p = 0.14). Multivariable analysis of mortality demonstrated that neutropenia increased mortality (adjusted odds ratio 10.05, 95% confidence interval 1.49 to 67.67, p = 0.02). Having a greater number of surgeries was associated with an increased rate of survival (adjusted odds ratio 0.39, 95% confidence interval 0.15 to 0.96, p = 0.04).
Invasive fungal sinusitis is an aggressive disease with significant mortality. Patients with neutropenia had a lower rate of survival, and infection with Zygomycota was associated with worse visual acuity outcomes. Those having functional endoscopic sinus surgery had better final visual acuity, and an increased number of surgeries was associated with a decreased chance of death. Exenteration yielded no observed survival benefit.Endoscopic sinus debridement portends better visual acuity outcomes in patients with invasive fungal sinusitis, whereas exenteration yields no difference in survival benefit.
侵袭性真菌性鼻窦炎是一种罕见但潜在致命的疾病，主要影响免疫功能低下的患者。本研究的目的是回顾一个学术医疗中心在侵袭性真菌性鼻窦炎的表现、诊断和治疗方面的经验。
在一家机构进行了为期 17 年的回顾性图表审查。分析了病历、影像学图像和手术报告。进行了双变量和多变量分析，以确定影响视力结果和死亡率的因素。
55 例经组织病理学证实的侵袭性真菌性鼻窦炎患者被纳入研究。平均随访时间为 1.8±2.6 年（范围：1 周至 10 年）。免疫抑制的最常见原因是血液恶性肿瘤（45%）、糖尿病（31%）和器官移植（9%）。在就诊时，35%的患者中性粒细胞减少（绝对中性粒细胞计数<500/μl）。所有患者均接受了全身抗真菌治疗。50 名患者（91%）接受了手术干预，除 1 名患者外，所有人均接受了功能性内镜鼻窦手术。9 名（16%）患者接受了眼眶切除术。视力结果的多变量分析表明，感染接合菌的患者视力比感染子囊菌的患者差 6-7 行（平均对数视力差 0.66，95%置信区间 0.27 至 1.06，p=0.001）。接受功能性内镜鼻窦手术的患者视力比未接受功能性内镜鼻窦手术的患者好 7-8 行（平均对数视力差-0.76，95%置信区间-1.13 至-0.38，p<0.001）。感染导致的总死亡率为 24%。双变量模型显示，接受眼眶切除术与未接受眼眶切除术的患者死亡率无差异（p=0.14）。死亡率的多变量分析表明，中性粒细胞减少增加了死亡率（调整后的优势比 10.05，95%置信区间 1.49 至 67.67，p=0.02）。手术次数增加与生存率提高相关（调整后的优势比 0.39，95%置信区间 0.15 至 0.96，p=0.04）。
侵袭性真菌性鼻窦炎是一种侵袭性疾病，死亡率较高。中性粒细胞减少的患者生存率较低，感染接合菌与视力结果较差相关。接受功能性内镜鼻窦手术的患者最终视力较好，手术次数增加与死亡机会降低相关。眼眶切除术并未带来观察到的生存获益。鼻窦内镜清创术在侵袭性真菌性鼻窦炎患者中可获得更好的视力结果，而眼眶切除术在生存获益方面无差异。
