4 Discussion
For patients with typical clinical features,diagnosis of AIFRS should
be alert
AIFRS is characterized by a rapid spread to adjacent orbits, cavernous
sinus, face, which need an urgent management, early diagnosis is very
important. To immunocompromised patients with severe underlying
diseases, such as AIDS, poorly controlled diabetic, haematological
malignancies undergoing chemotherapy or transplantation, if they were
afflicted by headache, eye pain, impaired vision, nasal obstruction, and
the symptom worsening rapidly, we should be highly alert the diagnosis
of AIFRS. Though lack specificity, some features of CT and MR Imaging
may help us to make such a diagnosis. For example, CT findings showed
unevenly increased density of soft tissues within involved nasal cavity
and sinus, spreading to adjacent
area with bone erosion. On MRI image, the lesion may show equal or
low signal on T1WI, while
relative high on T2WI, but
compared with acute suppurative inflammation, the signal of T2WI in
AIFRS still showed lower. Infection usually invaded to adjacent area
with unclear boundaries, predominant orbit and cavernous sinus. Usually
the lesion may uneven enhanced after enhancement. However, it’s worth
mentioning that if MR enhancement is not obvious, it means tissue
infarction with a necrotizing pathological reaction, and the prognosis
may even worse [3]. For highly suspected patients, smear or
fluorescent staining of secretions from eyes or nasal should be taken as
soon as possible to obtain a quick microbial evidence. In line with
literature, in most cases, intraoperative frozen section could offer us
a rapid diagnosis [4,5].
Surgicaldebridement: the more,
the better?
Principally, surgical debridement
should be carried out as soon as possible and as much as possible.
However, because of generally poor condition for such a group, operation
should be considered on a case-by-case basis. For example, case 6 and
case 8, after assessment, they were contraindicated for surgery because
of poor general condition. The extents of debridement were mainly based
on CT/MR, however, it was not always an intellectual decision to force a
complete debridement. For example, management on the area of orbital
apex and cavernous sinus were extremely difficult. Risk and benefit
should be carefully balanced. Anti-fungal treatment seemed equal
important. For example, case2, we only performed a complete debridement
of sphenoid sinus while left the orbital apex and the cavernous sinus in
place. Voriconazole was taken orally for 4 months after the operation
and the patient was cured during 58 months follow-up. The same result
displayed in case7. While for case3, though we gave the patient a
thoroughly debridement including enucleation of orbital contents.
However, due to the patient’s advanced age (74 years old), poor diabetes
mellitus, severe granulocytopenia and Mucor invasion, he still died of
multiple infections 1m after operation. According to literature,
survival rate seemed not improved by an aggressive
debridement such as orbital
contents enucleation, maxillectomy [1,6]. The outcomes of our group
supported such a conclusion.