Prospective Study
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Radiol. Dec 28, 2024; 16(12): 771-781
Published online Dec 28, 2024. doi: 10.4329/wjr.v16.i12.771
Proposed computed tomography severity index for the evaluation of invasive fungal sinusitis: Preliminary results
Smita Manchanda, Ashu S Bhalla, Ankita D Nair, Kapil Sikka, Hitesh Verma, Alok Thakar, Aanchal Kakkar, Maroof A Khan
Smita Manchanda, Ashu S Bhalla, Ankita D Nair, Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi 110029, India
Kapil Sikka, Hitesh Verma, Alok Thakar, Department of Otorhinolaryngology and Skull Base Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
Aanchal Kakkar, Department of Pathology, All India Institute of Medical Sciences, New Delhi 110029, India
Maroof A Khan, Department of Biostatistics, All India Institute of Medical Sciences, New Delhi 110029, India
Author contributions: Manchanda S and Bhalla AS designed the research study; Sikka K, Verma H, and Thakar A contributed to case referral and later follow-up of the cases; Nair AD contributed to data acquisition and organization; Manchanda S analyzed the data and wrote the manuscript; Nair AD also assisted in the editing of the manuscript; Kakkar A contributed to histopathological analysis; Khan MA participated in the study design and performed the statistical analysis; all authors have read and approved the final manuscript.
Supported by All India Institute of Medical Sciences, New Delhi, No. A-COVID-80.
Institutional review board statement: The study was reviewed and approved by the All India Institute of Medical Sciences, New Delhi Institutional Review Board (IEC -378/02.07.2021).
Clinical trial registration statement: No clinical registration statement applies to this study.
Informed consent statement: All study participants, or their legal guardian, provided written consent before study enrolment.
Conflict-of-interest statement: The authors of this manuscript have no conflicts of interest to disclose.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at ashubhalla2@gmail.com. Participants gave informed consent for data sharing.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ashu S Bhalla, MD, Professor, Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, Sri Aurobindo Marg, New Delhi 110029, India. ashubhalla1@yahoo.com
Received: June 5, 2024
Revised: October 24, 2024
Accepted: December 3, 2024
Published online: December 28, 2024
Processing time: 205 Days and 8 Hours
Abstract
BACKGROUND

Invasive fungal sinusitis (IFS) can present as a mild disease to life-threatening infection. A recent surge in cases was seen due to the coronavirus disease 2019 (COVID-19) pandemic. Many patients require surgical debridement and hence imaging [contrast-enhanced computed tomography (CECT) of the paranasal sinuses (PNS)] to document the extent of the disease. However, there was no scoring system using CECT to describe the severity of IFS. This study proposes a computed tomography (CT) severity index (CTSI) to describe the severity of rhino-orbital-cerebral involvement in symptomatic COVID-19 patients and hypothesizes that higher CTSI correlates with disease severity and thus slow response/non-response to treatment.

AIM

To propose a scoring system using CECT to describe the severity of IFS and correlate it with clinical outcomes.

METHODS

A prospective study on 66 COVID-19 positive patients with CECT PNS done for IFS was performed. Split-bolus single-phase CT technique was used. Based on the extent of involvement, a CTSI was designed. Disease in four major subsite areas was assessed. Each subsite involvement was given points according to this model and then summated. Based on the final summated CTSI, the disease was classified as mild, moderate, or severe. Two subsets were subsequently analyzed including survival and death; and responders and non-responders.

RESULTS

The study cohort was 66 COVID-19-positive patients with suspected IFS with a median age of 48.5 years. Mild disease was noted in 34 (51.52%), moderate in 28 (42.42%), and severe disease in 4 (6.06%) patients. There was a significant association of mortality and poor clinical response (P = 0.02) with disease bilaterality. Laterality and CTSI were significant predictors of response to treatment. The mean CTSI of responders was 6.3, of non-responders was 12.9 and the response to treatment was significantly associated with CTSI (t-test, P < 0.001). Receiver operating characteristic curve analysis (Liu method) to distinguish between responders and non-responders showed that the cut-off value for CTSI of 11 had a sensitivity of 78.26% and a specificity of 95.35% to predict response assessment.

CONCLUSION

CTSI can help in quantification of the disease burden, mapping out disease extent, triaging patients, and response assessment; especially patients with underlying comorbidities. A higher score would alert the clinician to initiate aggressive treatment, as severe disease correlates with slow response/non-response to the treatment.

Keywords: Mucormycosis; Aspergillosis; Invasive fungal sinusitis; Rhino- orbito-cerebral mucormycosis; COVID-19; Scoring system

Core Tip: This was a prospective study with 66 coronavirus disease 2019-positive patients in whom contrast-enhanced computed tomography (CECT) of the paranasal sinuses was done for invasive fungal sinusitis (IFS). It aimed to propose a scoring system [computed tomography severity index (CTSI)] using CECT to describe the severity of IFS and correlate it with clinical outcomes. Disease was categorized as mild, moderate, and severe based on CTSI. A higher score correlated with slow response/non-response to treatment in our study. Thus, CTSI can help in the quantification of the disease burden, triaging patients, and response assessment. A higher score would alert the clinician to initiate aggressive treatment, as severe disease correlates with slow response/non-response to treatment.