A Case of Relapse of Invasive Fungal Sinusitis after Endoscopic Sinus Surgery

Abstract

Invasive fungal sinusitis is considered to have a poor prognosis. We report herein on a case of invasive fungal sinusitis successfully treated with endoscopic sinus surgery (ESS) but which relapsed 4 months after surgery. A 65-year-old man presenting with left cheek pain was found on computed tomography to have a heterogeneously enhanced mass in the anterior wall of the maxillary sinus and bone defects. We suspected a malignant tumor and performed diagnostic ESS. Fungus and necrotic mucosa were observed in the posterior wall of the maxillary sinus while necrotic mucosa and bone destruction were observed in the anterior wall. Endoscopic findings indicated a diagnosis of invasive fungal sinusitis and the patient underwent removal of the mucosa of the maxillary sinus with a modified endoscopic medial maxillectomy. Pathology confirmed invasive fungal sinusitis and Aspergillus fumigatus was detected on bacterial testing. The patient’s left cheek pain disappeared after surgery and micafungin was systemically administered for one month. However, follow-up CT at 4 months after surgery revealed recurrence in the orbit. Voriconazole was systemically administered and ESS was performed to confirm the diagnosis. Since we suspected that the fungus had invaded the lateral aspect of the maxillary bone, a total maxillectomy was performed, followed by systematic administration of voriconazole for 2 months. The patient was free from recurrence at the one-year follow up. This case suggests that, depending on the clinical course, aggressive surgery such as a total maxillectomy might be required for invasive fungal sinusitis.