Combination antifungal therapy for invasive aspergillosis: can it replace high-risk surgery at the skull base?
OBJECTIVE
The increasing volume of literature on Aspergillus sinus infection is confusing because different authors stress different aspects of the disease. It is generally accepted that standard therapy consists of surgical debridement and medication with systemic amphotericin B. Patients who fail the standard therapy or those who cannot tolerate amphotericin B pose a dilemma. This study attempted to address the issues concerning combination therapy in invasive aspergillosis.


METHODS
We conducted a prospective randomized study on 6 apparently immunocompetent patients with invasive aspergillosis complicated by orbital and intracranial spread. All the patients were treated with a combination of amphotericin B (2.5 g) and itraconazole (6 months). They were monitored clinically and radiologically before, during, and after their combined antifungal therapy management.


RESULTS
Among the 6 immunocompetent patients, orbital involvement was seen in 5, skull base erosion with intracranial extension was seen in 2, and infratemporal fossa extension was seen in 2. After completion of treatment with 1.5 g of amphotericin, the paranasal sinus part of the lesion disappeared. However, there was residual lesion in the intracranial part that completely disappeared only after treatment with 2.5 g of amphotericin and 6 months of itraconazole therapy.


CONCLUSIONS
Invasive aspergillosis has been increasingly reported among immunocompetent patients. No single surgical or medical maneuver, including orbital exenteration, guarantees cure. The combination of amphotericin B and itraconazole for skull base aspergillosis represents a real step forward in the treatment of invasive aspergillosis.
Panda
Naresh K
NK
Department of Otolaryngology and Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India. npanda59@yahoo.co.in
Saravanan
Karuppiah
K
Chakrabarti
Arunaloke
A
D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use*; D001228:Aspergillosis / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery; D001706:Biopsy; D003646:Debridement / Q000379:methods*; D004724:Endoscopy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012852:Sinusitis / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery; D019291:Skull Base / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D000935:Antifungal Agents