Extensive Allergic Fungal Rhinosinusitis: Ophthalmic and Skull Base Complications

Abstract

To review the clinical features, ophthalmic and skull base complications, radiologic correlates, surgical methods and outcomes in cases of extensive allergic fungal rhinosinusitis (AFRS). The retrospective review was carried out at a tertiary referral center and included 11 patients with extensive AFRS. Inclusion criteria were confirmed cases of AFRS with intracranial extension, gross erosion of the skull base or medial orbital wall and/or ophthalmic complications of AFRS, including visual loss. Acute bacterial or invasive fungal sinusitis and other non-AFRS sinus pathologies with orbital or skull base complications were excluded from the study. The mean age of patients was 22.7 years. Proptosis was the most common presenting feature followed by diplopia and visual loss. Four patients exhibited unilateral visual loss with one case of sudden acute onset. Intracranial extradural spread to the middle cranial fossa was observed in two cases with cavernous sinus involvement, destruction of the entire cranial base and extension to the petrous temporal bone. Ten patients exhibited co-existing orbital and skull base erosion whereas gross erosion of the lamina papyracea alone was seen in one patient. All patients underwent endoscopic sinus surgery with complete disease clearance. The minimum and maximum follow-up periods were 1 and 3 years, respectively with one documented recurrence 18 months after surgery. Visual recovery was complete after sudden vision loss whereas it was only partial or absent in patients with prolonged vision loss. Cases of extensive AFRS with ophthalmic and skull base complications pose diagnostic and therapeutic challenges and merit early intervention with long-term follow-up.

The Different Clinical Presentations of Allergic Fungal Rhinosinusitis

“…Ashish V, et al has reported sudden visual loss in one of four patients. Patient had complete visual recovery (6/6) due to intravenous steroid administration even before surgical decompression [38]. In our case, patient's visual loss improved post operatively along with use of oral steroids as well.…”

“…The proximity of neurovascular structures to the nasal cavity and sinuses put them at risk of injury, either from the disease process itself or from surgical management. These structures include the internal carotid artery, cranial nerves, cavernous sinus, dura mater and cerebral lobes [38]. The expansion of the disease usually is determined by location of the disease, as well as the path of least resistance.…”

Odontogenic suppurative rhinosinusitis with oculo-orbital and cerebral complications - case series

“…Also the anaerobiosis favours the association with aspergilloma 4 . The spreading mecha-nisms leading to major complications are through continuity, contiguity and haematogenous spreading 5 . There are three possible major complications of RS: endocranial, oculo-orbital and broncho-pulmonary 6 .…”

Allergic fungal rhinosinusitis presenting with epiphora and blurry vision

“…Treatment for AFRS typically involves surgical and medical management . The most common ophthalmic features of AFRS are proptosis, diplopia and vision loss . Epiphora alone is an atypical presentation …”

“…1 The most common ophthalmic features of AFRS are proptosis, diplopia and vision loss. 5 Epiphora alone is an atypical presentation. 6 A 33-year-old man presented with complaints of chronic epiphora in both eyes and blurry vision in the left eye.…”