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.