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LETTER TO EDITOR
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 89-90

Orbital apex syndrome due to invasive aspergillus flavus sinusitis


Department of General Medicine, MES Medical College, Perinthalmanna, Kerala, India

Date of Submission09-Jun-2019
Date of Acceptance20-Oct-2019
Date of Web Publication25-Nov-2019

Correspondence Address:
Prof. Mansoor C Abdulla
Department of General Medicine, MES Medical College, Perinthalmanna - 679 338, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_13_19

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How to cite this article:
Abdulla MC. Orbital apex syndrome due to invasive aspergillus flavus sinusitis. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2019;3:89-90

How to cite this URL:
Abdulla MC. Orbital apex syndrome due to invasive aspergillus flavus sinusitis. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2019 [cited 2019 Dec 9];3:89-90. Available from: http://www.aiaohns.in/text.asp?2019/3/2/89/271595



Sir,

A 76-year-old female presented with a headache for 3 months, progressive painful loss of vision right eye, and drooping of the right upper eyelid for 2 weeks. She had no history of fever, altered sensorium, seizure, and diplopia. She had a history of diabetes mellitus and hypertension in the past but had no sick contacts or history of addictions. On examination, there was complete right-sided ophthalmoplegia, first trigeminal division hypoalgesia, and severe visual loss in the right eye. Fundoscopy showed proliferative diabetic retinopathy in both eyes. Magnetic resonance imaging of the brain showed a focal lesion in the sphenoid sinus focally extending to the right orbital apex and mild optic nerve tortuosity. The computed tomography of the orbit showed heterogeneous soft-tissue mass involving the roof of the right sphenoid sinus with bony erosion and extension to the right orbital apex [Figure 1]a and [Figure 1]b. The histopathological specimen from the sinus revealed slender fungal hyphae with septation surrounded by chronic granulomatous inflammation on hematoxylin and eosin stain and long conidiophores with tangled web appearance on lactophenol cotton blue mount [Figure 1]c and [Figure 1]d. The Sabouraud dextrose agar showed the growth of yellow–green colonies. The isolate was identified as Aspergillus flavus. She was started on voriconazole 6 mg/kg for 1 day, then 4 mg/kg/day intravenous twice daily for 2 weeks and was continued with oral voriconazole 200 mg twice daily thereafter. The patient's ophthalmoplegia and visual acuity improved partly after 2 weeks of treatment.
Figure 1: The computed tomography of orbit axial view showing heterogenous soft-tissue mass involving the roof of right sphenoid sinus with bony erosion and extension to right orbital apex (a and b). Biopsy of the orbital and sinus tissue showing fungal hyphae with septation hematoxylin and eosin stain, ×400 (c). Long conidiophores and Tangled web appearance on lactophenol cotton blue mount × 400 (d)

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Orbital apex syndrome (OAS) is characterized by the involvement of the extraocular muscles, the ophthalmic branch of the trigeminal nerve, and the optic nerve. OAS can be secondary to a variety of etiologies, including inflammation, infection, vasculitis, and malignancy. Fungal rhinosinusitis is an aggressive infection seen usually in immunocompromised patients. Sino-orbital aspergillosis and mucormycosis are the two infections in diabetic patients, which can result in life-threatening complications. A systematic literature review of patients with sino-orbital aspergillosis identified only five case reports with orbital complications.[1] There were even cases of invasive sino-orbital aspergillosis misdiagnosed with paranasal sinus tumors, resulting in delayed antifungal therapy.[1],[2] Identifying the exact etiology and the species if fungal is crucial for a good outcome. OAS due to invasive aspergillosis has a good prognosis, with prompt control of the predisposing factor and early management by antifungal therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chang YM, Chang YH, Chien KH, Liang CM, Tai MC, Nieh S, et al. Orbital apex syndrome secondary to aspergilloma masquerading as a paranasal sinus tumor: A case report and literature review. Medicine (Baltimore) 2018;97:e11650.  Back to cited text no. 1
    
2.
Fernandes YB, Ramina R, Borges G, Queiroz LS, Maldaun MV, Maciel JA Jr. Orbital apex syndrome due to aspergillosis: Case report. Arq Neuropsiquiatr 2001;59:806-8.  Back to cited text no. 2
    


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