Management of Invasive Fungal Sinusitis with Intracranial Involvement

Introduction: Invasive fungal sinusitis (IFS) is an uncommon but fulminant disease of the nose and paranasal sinuses most often seen in immunocompromised patients. Through tissue and blood vessel invasion, the fungal infection can rapidly extend into the orbit and even penetrate the skull base; however, intracranial invasion is rare. Over the past 20 years, only 31 cases have been reported in the literature with a cumulative short-term mortality of 65%. Although emergent surgery and antifungal therapy are generally accepted as the appropriate treatment of IFS, the aggressiveness of the surgery and the type and duration of antifungal medications are not standardized, especially in the setting of intracranial disease. The aim of this study is to evaluate aggressive surgery and long-term antifungal treatment for intracranial IFS. Methods: Case series and review of the literature. Results: We present a series of three immunocompromised patients with invasive fungal sinusitis with intracranial involvement over a 1-year period. Resection of sinonasal and intracranial disease was performed endoscopically in all three patients, with an additional open approach in two patients. All three patients received 6 months of antifungals postoperatively. At 6-month follow-up, all were disease free based on clinical examination and serial MRI. Conclusion: Invasive fungal sinusitis with intracranial involvement is associated with high rates of mortality. Aggressive surgical and medical therapy can drastically improve patient outcomes, with 100% survival in our series on short-term follow-up. The presence of intracranial disease burden on this small series does not directly correlate with 100% progression in the setting of aggressive treatment.