BACKGROUND:Orbital involvement of invasive fungal sinusitis (IFS) is an ominous prognostic marker that should prompt rapid intervention. Transcutaneous retrobulbar administration of amphotericin B (TRAMB) is an off-label adjunctive treatment that can increase drug penetrance into diseased orbital tissue. To date, there is a lack of consensus regarding the use of TRAMB for treatment of IFS with orbital involvement. OBJECTIVE:This systematic review aims to synthesize the indications, efficacy, and potential complications of TRAMB. METHODS:PubMed, EMBASE, and Web of Science databases were probed for systematic review. Article search was conducted through June 2023 using the keywords "invasive fungal sinusitis," "invasive fungal rhinosinusitis," "rhino-orbital mucormycosis," "rhinosinusitis," "orbital," "retrobulbar," and "amphotericin." RESULTS:In suitable cases as determined by radiologic and clinical evaluation, TRAMB administration has the potential to improve orbital salvage rates and improve versus stabilize visual acuity. Treatment complications are more likely with deoxycholate than with liposomal amphotericin formulations. The existing literature describing use of TRAMB is limited due to its retrospective nature, but the increase in IFS cases since 2020 due to the COVID pandemic has broadened the literature. CONCLUSIONS:TRAMB is an effective adjunctive treatment in IFS with mild-to-moderate orbital involvement when used in combination with standard of care debridement, systemic antifungal therapy, and immunosuppression reversal. Prospective longitudinal studies and multi-institutional randomized trials are necessary to determine the definitive utility of TRAMB.

BackgroundAcute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. MethodsThe PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. ResultsA review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. ConclusionBased on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.

BACKGROUND:Acute invasive fungal sinusitis (AIFS) is an aggressive and dangerous disease of the paranasal sinuses with high morbidity and mortality. The immune response at the level of the nasal mucosa, the site of entry, has not been previously evaluated.OBJECTIVE:To evaluate differential gene expression in the sinonasal mucosa of AIFS patients as compared to control patients using RNA sequencing.METHODS:Sinonasal tissue samples were prospectively obtained from consenting patients undergoing surgery between November, 2020 and November, 2021. RNA extraction and sequencing were performed and differential expression was analyzed to detect transcriptional differences between patient groups.RESULTS:Tissue samples were collected from 4 patients with active AIFS diagnoses, 2 patients with recovered AIFS, 1 patient with a diagnosis of non-invasive fungal ball, and 4 healthy controls. 255 genes were differentially expressed in AIFS patients as compared to control patients. Specific Gene Ontology (GO) biological processes that were identified as differentially expressed in AIFS patients as compared to controls included the following: 1. GO:0007155 (cell adhesion), 2. GO:0030199 (collagen fibril organization) and 3. GO:0001525 (angiogenesis).CONCLUSION:Transcriptional differences were noted between AIFS and control patients in sinonasal tissue samples. Future work is necessary to determine causes of the differential gene expressions between AIFS and control patients, specifically those who are immunosuppressed, or with preexisting non-invasive forms of fungal sinusitis, to guide treatment and prevention strategies.

The authors have no conflicts of interest to disclose. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Purpose: To identify initial, preintervention magnetic resonance imaging (MRI) findings that are predictive of visual and mortality outcomes in acute invasive fungal rhinosinusitis (AIFRS). Design: Retrospective cohort study. Participants: Patients with histopathologically or microbiologically confirmed AIFRS cared for at a single, tertiary academic institution between January 2000 and February 2020. Methods: A retrospective review of MRI scans and clinical records of patients with confirmed diagnosis of AIFRS was performed. For each radiologic characteristic, a modified Poisson regression with robust standard errors was used to estimate the risk ratio for blindness. A multivariate Cox proportional hazards model was used to study AIFRS-specific risk factors associated with mortality. Main Outcome Measure: Identification of initial, preintervention MRI findings associated with visual and mortality outcomes. Results: The study comprised 78 patients (93 orbits, 63 with unilateral disease and 15 with bilateral disease) with AIFRS. The leading causes of immunosuppression were hematologic malignancy (38%) and diabetes mellitus (36%). Mucormycota constituted 56% of infections, and Ascomycota constituted 37%. The overall death rate resulting from infection was 38%. Risk factors for poor visual acuity outcomes on initial MRI included involvement of the orbital apex (relative risk [RR], 2.0; 95% confidence interval [CI], 1.1-3.8; P = 0.026) and cerebral arteries (RR, 1.8; 95% CI, 1.3-2.5; P < 0.001). Increased mortality was associated with involvement of the facial soft tissues (hazard ratio [HR], 4.9; 95% CI, 1.3-18.2; P = 0.017), nasolacrimal drainage apparatus (HR, 5.0; 95% CI, 1.5-16.1; P = 0.008), and intracranial space (HR, 3.5; 95% CI, 1.4-8.6; P = 0.006). Orbital soft tissue involvement was associated with decreased mortality (HR, 0.3; 95% CI, 0.1-0.6; P = 0.001). Conclusions: Extrasinonasal involvement in AIFRS typically signals advanced infection with the facial soft tissues most commonly affected. The initial, preintervention MRI is prognostic for a poor visual acuity outcome when orbital apex or cerebral arterial involvement, or both, are present. Facial soft tissues, nasolacrimal drainage apparatus, intracranial involvement, or a combination thereof is associated with increased mortality risk, whereas orbital soft tissue involvement is correlated with a reduced risk of mortality. (C) 2022 by the American Academy of Ophthalmology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Bawaadam, Hasnain S. MD; Russell, Matthew MD, FACS; Gesthalter, Yaron B. MD Author Information

We report a liver transplant patient with disseminated Legionella micdadei infection with pulmonary, laryngeal, and suspected muscle involvement. This organism, which stains weakly acid-fast, primarily affects immunocompromised patients. The diagnosis is difficult to make; in this case, the organism was identified via molecular diagnostics on laryngeal and pulmonary biopsy tissue.

BACKGROUND:During the SARS-CoV-2 pandemic, tracheostomy may be required for COVID-19 patients requiring long-term ventilation in addition to other conditions such as airway compromise from head and neck cancer. As an aerosol-generating procedure, tracheostomy increases the exposure of health care workers to COVID-19 infection. Performing surgical tracheostomy and tracheostomy care requires a strategy that mitigates these risks and maintains the quality of patient care. METHODS:This study is a multidisciplinary review of institutional tracheostomy guidelines and clinical pathways. Modifications to support clinical decision making in the context of COVID-19 were derived by consensus and available evidence. RESULTS:Modified guidelines for all phases of tracheostomy care at an academic tertiary care center in the setting of COVID-19 are presented. DISCUSSION:During the various phases of the COVID-19 pandemic, clinicians must carefully consider the indications, procedural precautions, and postoperative care for tracheostomies. We present guidelines to mitigate risk to health care workers while preserving the quality of care.

Posterior fossa meningiomas that impinge on structures of the temporal bone or clivus may be difficult to access for optimal resection that maximizes tumor control and minimizes short- and long-term morbidities. To address this challenge, the contemporary neurosurgery-neurotology team works collaboratively by managing patients jointly at every stage of care: preoperative evaluation, intraoperative intervention, and postoperative treatment. The neurotologist is important at all stages of posterior fossa meningioma surgery. First, detailed preoperative evaluation of auditory, facial, vestibular, and lower cranial nerve integrity enables assessment of new neurologic deficit risk, prognosis of functional recovery, and pros and cons of candidate surgical approaches. Second, intraoperative partitioning of surgical steps by provider and adopting an overlapping tumor resection philosophy creates an efficient and confident surgical team built on trust. Third, postoperative closure of cerebrospinal fluid leak and treatment of facial weakness, audiovestibular dysfunction, and voicing and swallowing impairments organized by the neurotologist reduces the impact of negative outcomes. The role of the neurotologist in posterior fossa meningioma surgery is to deliver nuanced evaluative metrics, facilitate shared decision making, perform precise bone and soft tissue microsurgery, and mitigate perioperative morbidities.

Objective To report on the incidence of dysphagia, dysphonia, and acute vocal fold motion impairment (VFMI) following revision anterior cervical spine surgery, as well as to identify risk factors associated with acute VFMI in the immediate postoperative period. Study Design Retrospective cohort study. Setting Tertiary care center. Subjects and Methods All patients who underwent 2-team reoperative anterior cervical discectomy and fusion (ACDF) were retrospectively reviewed. Incidence of dysphonia, dysphagia, and acute VFMI was noted. Patient and operative factors were evaluated for association with risk of acute VFMI. Results The incidence of postoperative dysphonia and dysphagia was 25% (18/72) and 52% (37/72), respectively. The incidence of immediate VFMI was 21% (15/72). Subjective postoperative dysphonia (odds ratio, [OR] 8; 95% CI, 2.2-28; P = .001) and dysphagia (OR, 22; 95% CI, 2.5-168; P = .005) were significantly associated with increased risk of VFMI. Three patients with VFMI required temporary injection medialization for voice complaints and/or aspiration. Infection (OR, 14; 95% CI, 1.4-147, P = .025) and level C7/T1 (OR, 5.5; 95% CI, 1.3-23, P = .02) were significantly associated with an increased risk of acute VFMI on multivariate logistic regression analysis. Number of prior surgeries, laterality of approach, side of approach relative to prior operations, and number of levels exposed were not significant. Conclusion Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.

•Bedside Percutaneous Dilational Tracheotomies have not replaced formal open tracheotomies in all critical care patients.•Tracheotomy consultations from the Intensive Care Unit should be systematic with special attention to pulmonary, cardiac, and laboratory evaluation. A sample safety checklist for consultation is provided.•Maintenance of a definitive airway with ventilation during tracheotomy requires the anesthesia provider to closely manage the endotracheal tube, including adjusting the tube position and cuff inflation.

Infections of the head and neck are common and appropriately managed by primary care providers in most cases. However, some infections are associated with significant morbidity and require urgent recognition and management by specialty services. These include deep neck space infections originating in the oral cavity, pharynx, and salivary glands, as well as complicated otologic and sinonasal infection. This article provides a review of these conditions, including the pathophysiology, presenting features, and initial management strategy.

BACKGROUND:Surgical access to Meckel's Cave (MC) is challenging due to its deep location and surrounding important neurovascular structures. Currently existing endoscopic endonasal (EE) approaches require dissecting near the internal carotid artery (ICA) or require transposition of the pterygopalatine neurovascular bundle. OBJECTIVE:To describe a novel approach to access the anterolateral aspect of the MC using a minimally invasive EE route. METHODS:The EE transmaxillary transinferior orbital fissure approach was simulated in 10 specimens. The approach included an ethmoidectomy followed by an extended medial maxillectomy with transposition of the nasolacrimal duct. The infraorbital fissure was opened, and the infraorbital neurovascular bundle was transposed inferiorly. A quadrilateral space, bound by the maxillary nerve inferomedially, ophthalmic nerve superomedially, infraorbital nerve inferolaterally, and floor of the orbit superolaterally, was exposed. The distances from the foramen rotundum (FR) to the ICA, orbital apex (OA), and infratemporal crest (ITC) and from the OA to the ICA and ITC were measured. RESULTS:The distances obtained were FR-ICA = 19.42 ± 2.03 mm, FR-ITC = 18.76 ± 1.75 mm, FR-OA = 8.54 ± 1.34 mm, OA-ITC = 19.78 ± 2.63 mm, and OA-ICA = 20.64 ± 142 mm. Two imaginary lines defining safety boundaries were observed between the paraclival ICA and OA, and between the OA and ITC (safety lines 1 and 2). CONCLUSION:The reported approach provides a less invasive route compared to contemporary approaches, allowing expanded views and manipulation anteromedial and anterolateral to MC. It may be safer than the existing approaches as it does not require transposition of the ICA, infratemporal fossa, and pterygopalatine fossa, and allows access to tumors located anteriorly on the floor of the middle cranial fossa.

A 68-year-old immunocompromised man with rhino-orbital-cerebral mucormycosis was treated with retrobulbar injections of amphotericin B deoxycholate in conjunction with intravenous antifungals and endoscopic sinus debridement. Transient episodes of orbital inflammation were noted after retrobulbar injections, but progression of orbital infection was halted and visual acuity restored with eventual hospital discharge. To the authors' knowledge, clearance of orbital mucormycosis with retrobulbar amphotericin B injections has not been previously reported. This intervention may be a viable therapeutic option in cases of orbital mucormycosis where aggressive orbital debridement is not favored and/or the burden of orbital disease is not substantial. However, physicians should be aware of the risk of transient orbital inflammation secondary to retrobulbar amphotericin B deoxycholate.

Dual island “paddle flaps” first described by Yu et al have demonstrated great utility in pharyngoesophageal and anterior neck reconstruction.[1] These fasciocutaneous flaps are tubed for the pharyngoesophageal reconstruction and a separate paddle is used for external skin reconstruction and Doppler monitoring. This technique has also found success in treating pharyngocutaneous fistulas.[2] Two case series have demonstrated good clinical and functional results with minimal morbidity using anterolateral thigh (ALT) dual island flaps for complex pharyngoesophageal, tracheal, and anterior neck defects.[1] [3] Ferguson and Yu described the use of the most distal skin of the ALT as an inconspicuous external skin-monitoring paddle for use in pharyngeal reconstruction, with very low incidence of fistula and/or stricture.[4] While Yu described repairing flat tracheal defects with such dual island paddle flaps,[1] no cases of circumferential tracheal reconstruction with such a dual island flap have been described.

Clinical & Experimental OphthalmologyVolume 42, Issue 9 p. 885-887 Letter to the Editor Loss of contrast enhancement of the inferior rectus muscle on magnetic resonance imaging in acute fulminant invasive fungal sinusitis Ian R Gorovoy MD, Ian R Gorovoy MD Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USASearch for more papers by this authorM Reza Vagefi MD, M Reza Vagefi MD Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USASearch for more papers by this authorMatthew S Russell MD, Matthew S Russell MD Department of Otolaryngology – Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USASearch for more papers by this authorMia Gorovoy MD, Mia Gorovoy MD Department of Radiology, Stanford University, Palo Alto, California, USASearch for more papers by this authorMichele M Bloomer MD, Michele M Bloomer MD Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USASearch for more papers by this authorChristine M Glastonbury MBBS, Christine M Glastonbury MBBS Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USASearch for more papers by this author Ian R Gorovoy MD, Ian R Gorovoy MD Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USASearch for more papers by this authorM Reza Vagefi MD, M Reza Vagefi MD Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USASearch for more papers by this authorMatthew S Russell MD, Matthew S Russell MD Department of Otolaryngology – Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USASearch for more papers by this authorMia Gorovoy MD, Mia Gorovoy MD Department of Radiology, Stanford University, Palo Alto, California, USASearch for more papers by this authorMichele M Bloomer MD, Michele M Bloomer MD Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USASearch for more papers by this authorChristine M Glastonbury MBBS, Christine M Glastonbury MBBS Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USASearch for more papers by this author First published: 26 March 2014 https://doi.org/10.1111/ceo.12337Citations: 12 Conflict/competing interest: No stated conflict of interest. Funding sources: No stated funding sources. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume42, Issue9December 2014Pages 885-887 RelatedInformation

Invasive facial fungal infections affect the orofacial soft tissues in immunocompromised patients and can cause significant morbidity and mortality. Primary infection occurs from direct inoculation of the skin surface, while secondary infection occurs from extension from an adjacent sinonasal process. The imaging features of secondary infection are similar to acute fulminant invasive fungal sinusitis with infiltration of the orofacial soft tissues in combination with sinonasal disease. However, primary infection can occur in the absence of sinonasal disease, making diagnosis challenging. We present two cases, one of primary and one of secondary invasive facial fungal infection. Careful scrutiny of the orofacial soft tissues in immunocompromised patients is necessary to detect invasive facial fungal infections so that appropriate surgical and medical therapies can maximize patient outcomes.

Objectives/Hypothesis: To define a new clinical hospitalist practice paradigm originating at the University of California, San Francisco.Design: Retrospective administrative database review at a tertiary referral hospital.Materials and Methods: A consortium model of an otolaryngologist hospitalist practice was developed. Billing records, including Current Procedural Terminology (CPT) and International Classification of Disease-9 (ICD-9) codes, were reviewed to evaluate the number and type of consultations and surgeries generated during a 2-year period.Results: A total of 375 new inpatient consultations generated 951 patient encounters. The most common diagnoses were respiratory failure (12%), sinusitis (10.6%), stridor (10.6%), and dysphonia (7.6%). Twenty-six percent of consultations involved a procedure or surgical intervention, the most common of which were endoscopic sinus surgery, laryngoscopy, and tracheotomy.Conclusions: To our knowledge, ours is the first full-time otolaryngology hospitalist model in the United States. The hospitalist practice is a conceptually viable and clinically beneficial paradigm that should be considered at other similar institutions.