gms | German Medical Science

Functional endoscopic sinus surgery (FESS) is a relatively new surgical procedure that has become the mainstay of the surgical diagnosis and treatment of sinusitis. FESS allows for determination of the bacterial or fungal etiology of sinusitis in immunocompromised children. Accurate diagnosis of sinusitis in these patients is particularly important given the fulminate nature of these infections, and given the ever expanding arsenal of potent (and expensive) antibiotics and antifungals at our disposal. Endoscopic debridement of necrotic tissue in patients with fungal sinusitis is an integral part of the treatment of this infection.

We reviewed the children undergoing FESS in the Department of Pediatric Hematology Oncology of Schneider Children's Medical Center between 2005- 2013.

Forty nine FESS procedures were performed in 28 patients (median age 10 years). Primary diagnosis was leukemia in 75% of patients (39% ALL, 36% AML, 13% Lymphomas, 12% others) Half of the patients had active relapses at the time of FESS, and 28% of all procedures were performed in patients following stem cell transplantation. Fever was present in all patients, and in most of the cases prolonged (median 14.5 days). Eighty three percent of the cases occurred in the context of profound and prolonged neutropenia (14 days median).

Computerized Tomography of the sinuses, performed in all the patients, revealed bone destruction in 2 cases. Asymmetric involvement of the sinuses was seen in10 studies. FESS revealed fungal infections in all these patients.

FESS permitted diagnosis of fungal infection in 17 patients (culture or PCR), including Zygomycoses (8) and Aspergillosis (6).Three of these patients had mixed Zygomices and Aspergillus infections.

Most of the patients with fungal sinusitis underwent more than one FESS (2 procedures in10 patients. 3 in 4 patients and in one case four) to facilitate complete surgical debridement. No significant complications were reported. Eight patients had negative FESS, and four had bacterial sinusitis.

Directed anti-fungal treatment was administered using either amphotericin or Voriconazole or combined therapy with Amphotericin B and Voriconazole. Or combinations of Ambisome and Posaconazole in cases of confirmed zygomices. The mortality was 57% in Zygomicosis infections and 33% in Aspergillosis. In mixed infections it was 50%.

FESS is an important diagnostic and treatment tool in immunocompromised children with sinus infection. A high index of suspicion and timely and aggressive intervention in collaboration with an ENT surgeon is vital.