3.1 Typical clinic features aided to a rapid diagnosis
All 8 patients had severe immunocompromised disease, i.e. poorly controlled diabetes, malignant hematological diseases, cancer (advanced stage) undergoing chemotherapy afflicted with granulocytopenia, renal insufficiency. The primary and main symptoms were severe headache, progressive eye disorder, facial pain. Because of severe underlying disease, 7/8 patients firstly admitted to corresponding department, after multi-disciplinary treatment (MDT) consultation, they were transferred to ENT department (table 1). Radiological features: computed tomography (CT) and magnetic resonance imaging (MRI) were used preoperatively to determine the extent of fungal invasion, all patients showed extra-sinus dissemination: orbit and orbital apex(5/8), cavernous sinus(2/8), face(3/8), palate(2/8). 6/8 patients had unilateral involvement and 2 patients with bilateral involvement. CT often showed heterogeneous opacity with or without bone erosion. MR usually showed a relative hypointense signal in T2W1 compared with bacterial inflammation, and an uneven enhancement in enhanced T1-weighted image. The main radiological findings with CT/MRI and endoscopic findings were summarized in Fig1-2 and supplementary Fig1-4 respectively. Based on an immunosuppressive history, rapid spread of orbit-cranial-face invasion, and radiological features, all cases were suspicion as AFIRS at first glance. Among them, 6 cases were pathologically confirmed after operation, 1 case was microbiological confirmed as Rhizopus and the other one evidenced by gross sign of mucor growth.