A Comparative Study of Acute Invasive Fungal Sinusitis During the First and Second Waves of the COVID-19 Pandemic.

We aimed to compare the demography, clinical profile, histopathology, fungal culture, radiology, surgery performed, medical therapy and outcomes of patients with acute invasive fungal sinusitis seen during the first and second waves of the COVID-19 pandemic by retrospectively reviewing their case records. Of 238 patients, 43(18.1%) presented during the first wave and 195(81.9%) during the second wave. Patients seen during the first wave were older (p = 0.04) and more likely to have visual impairment (p = 0.004), frozen eye (p = 0.012), altered sensorium (p = 0.007) and stage 3 disease (p = 0.03). Those seen during the second wave were more often COVID-19 positive and had newly diagnosed diabetes mellitus (p = 0.04)and stage 1 disease (p = 0.03). Most patients had a positive culture for Rhizopus species during both waves. Histopathology showed broad aseptate hyphae in all patients but angioinvasion was seen more often during the first wave (p = 0.04). The majority of patients were treated with endoscopic+/- open debridement followed by intravenous amphotericin B and oral posaconazole. While the overall survival rate was similar (first wave 65.1%; second wave 79%; p = 0.106), mortality after discharge was greater during the first wave (11.6% vs 1.5%; p = 0.001). Mortality was higher in patients with stage 3 disease (p = 0.003). Significant differences in clinical presentation, histopathology, radiological stage of disease and post-discharge survival were noted between the two waves of the COVID-19 pandemic, the causes for which were multi-factorial.

Post-traumatic transocular retained foreign body in the infratemporal fossa: a near miss.

The infratemporal fossa is an uncommon site for lodgement of foreign bodies. Fast-moving projectiles and displaced teeth may get impacted and have been described in the literature. However, foreign body lodgement in the retromaxillary space after transorbital passage is rare. The trajectory of the foreign bodies in such cases is difficult to predict and may not be suspected in the absence of overt clinical features. The authors present a case of a wooden splinter lodged within the infratemporal fossa after the patient sustained a lid injury with an orbital floor fracture. Imaging was equivocal; hence, endoscopic surgical exploration was undertaken, revealing the foreign body. A high index of clinical suspicion and rapid intervention is needed since unsuspected foreign bodies may cause further visual, infective or neurovascular complications. Approaches should be tailored on a case-by-case basis.

Threshold and suprathreshold component analysis in olfactory dysfunction: a retrospective study.

OBJECTIVE: To analyse variations in the n-butanol threshold and odour identification scores of the Connecticut Chemosensory Clinical Research Centre test in various grades of olfactory dysfunction and in different nasal conditions leading to olfactory loss. METHOD: Retrospective observational study. RESULTS: All grades of olfactory dysfunction were predominantly noted among males. In chronic rhinosinusitis, anosmia or severe hyposmia was seen in 87.5 per cent of patients without polyps in comparison with 68 per cent of patients with polyps. In addition, 90 per cent of patients with atrophic rhinitis and post-traumatic loss had anosmia, but only 30.7 per cent of patients with allergic rhinitis had anosmia. Pepper was the most affected smell for all the nasal diseases except atrophic rhinitis, in which asafoetida and baby powder smells were affected more. CONCLUSION: In most inflammatory sinonasal conditions, odour identification is relatively preserved even when the threshold is maximally affected. In patients with comparable olfactory dysfunction based on the Connecticut Chemosensory Clinical Research Centre test score, a relatively preserved suprathreshold odour identification score may predict better prognosis.

Whole genome analysis of Rhizopus species causing rhino-cerebral mucormycosis during the COVID-19 pandemic.

Introduction: Mucormycosis is an acute invasive fungal disease (IFD) seen mainly in immunocompromised hosts and in patients with uncontrolled diabetes. The incidence of mucormycosis increased exponentially in India during the SARS-CoV-2 (henceforth COVID-19) pandemic. Since there was a lack of data on molecular epidemiology of Mucorales causing IFD during and after the COVID-19 pandemic, whole genome analysis of the Rhizopus spp. isolated during this period was studied along with the detection of mutations that are associated with antifungal drug resistance. Materials and methods: A total of 50 isolates of Rhizopus spp. were included in this prospective study, which included 28 from patients with active COVID-19 disease, 9 from patients during the recovery phase, and 13 isolates from COVID-19-negative patients. Whole genome sequencing (WGS) was performed for the isolates, and the de novo assembly was done with the Spades assembler. Species identification was done by extracting the ITS gene sequence from each isolate followed by searching Nucleotide BLAST. The phylogenetic trees were made with extracted ITS gene sequences and 12 eukaryotic core marker gene sequences, respectively, to assess the genetic distance between our isolates. Mutations associated with intrinsic drug resistance to fluconazole and voriconazole were analyzed. Results: All 50 patients presented to the hospital with acute fungal rhinosinusitis. These patients had a mean HbA1c of 11.2%, and a serum ferritin of 546.8 ng/mL. Twenty-five patients had received steroids. By WGS analysis, 62% of the Rhizopus species were identified as R. delemar. Bayesian analysis of population structure (BAPS) clustering categorized these isolates into five different groups, of which 28 belong to group 3, 9 to group 5, and 8 to group 1. Mutational analysis revealed that in the CYP51A gene, 50% of our isolates had frameshift mutations along with 7 synonymous mutations and 46% had only synonymous mutations, whereas in the CYP51B gene, 68% had only synonymous mutations and 26% did not have any mutations. Conclusion: WGS analysis of Mucorales identified during and after the COVID-19 pandemic gives insight into the molecular epidemiology of these isolates in our community and establishes newer mechanisms for intrinsic azole resistance.

Relationship of Upper Airway Collapse with Severity of Sleep Apnoea and Sleepiness.

Introduction: Obstructive sleep apnoea (OSA) is characterized by repeated episodes of upper airway collapse. A review of literature shows limited and conflicting data regarding impact of upper pharyngeal collapse on severity of OSA and degree of sleepiness. Objective: To evaluate the association of the number of levels and degree of upper airway collapse and severity of OSA. Methods: This is a retrospective study including all patients with OSA over a two-year period. Data regarding neck circumference (NC), body mass index (BMI), nasopharyngolaryngoscopy with Muller's manoeuvre, Epworth sleepiness scale (ESS) questionnaire and a full night polysomnography were collected. Correlation of the number of sites involved and degree of collapse at each site (velum, lateral pharyngeal wall- Level I, base of tongue - Level II and epiglottis - Level III) with BMI, NC, AHI and ESS were assessed. Results: Of the 144 patients, 98% had collapse at Level I. 80% of patients had multisegmental collapse with 30% having collapse at all three levels. The number of levels and the severity of collapse did not have a proportionate effect on the AHI and ESS and were not directly dependent on the BMI. However, changes in NC had a significant effect on the severity of collapse.Conclusion: Severity of OSA and degree of sleepiness were not directly dependent on the severity and the number of levels of collapse. Since majority of the patients had multi segmental collapse, the study highlights the importance of careful assessment of all levels to tailor management strategies for optimum patient management.

Short intravenous amphotericin B followed by oral posaconazole using a simple, stratified treatment approach for diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis: a prospective cohort study.

OBJECTIVES: To evaluate the efficacy and safety of short-course intravenous amphotericin B followed by sustained release posaconazole tablets for diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis. METHODS: This prospective, pragmatic study included adults with diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis. Patients received short (7-14 days) or long (15-28 days) intravenous antifungal therapy (short intravenous antifungal treatment [SHIFT] or long intravenous antifungal treatment [LIFT], respectively) depending on the presence or absence of brain involvement. All patients received step-down posaconazole tablets, debridement, and glycemic control. The primary outcome was the treatment success at week 14, which was determined by assessing survival and the absence of disease progression through clinical evaluation and nasal endoscopy. Log-binomial regression analysis (risk ratio and 95% CI) was performed to assess factors associated with the primary outcome. RESULTS: Intravenous therapy was administered to 251 participants: SHIFT, 205 (median duration, 13 days); LIFT, 46 (median duration, 22 days). Treatment success at 3 months was 88% (217/248; 95% CI, 83-91%): SHIFT group, 93% (189/203; 89-96%); LIFT group, 62% (28/45; 47-76%). All-cause mortality was 12% (30/251): SHIFT group, 6% (13/205); LIFT group, 37% (17/46). Age (aRR [95% CI]: 1.02 [1.00-1.05]; p 0.027), diabetic ketoacidosis at presentation (2.32 [1.20-4.46]; p 0·012), glycated haemoglobin A1c (1.19 [1.03-1.39]; p 0.019), stroke (3.93 [1.94-7.95]; p 0·0001), and brain involvement (5.67 [3.05-10.54]; p < 0.0001) were independently associated with unsuccessful outcomes. DISCUSSION: Short intravenous amphotericin B with step-down posaconazole tablets should be further studied as primary treatment option for diabetes or COVID-19-associated mucormycosis in randomized controlled trials.

Clinicopathological predictors of repeated recurrence in sinonasal inverted papilloma.

PURPOSE: To evaluate association between clinical and pathological findings and repeated recurrence in sinonasal inverted papilloma. METHODS: Retrospective cohort study conducted at a tertiary care teaching hospital included all patients operated for inverted papilloma from January 2010 to December 2019. Patients were categorized as primary and recurrent cases. Based on disease status at follow-up, they were subcategorized into 'primary with no recurrence' (PnR), 'primary with recurrence' (PwR), 'recurrent with no further recurrence' (RnR), and 'recurrent with further recurrence' (RwR) groups. Data including demography, clinical, endoscopic and pathological findings were collected and analyzed. RESULTS: Increased incidence of pale appearance of lesion in RnR group (p = 0.017), polypoidal appearance in primary group (p = 0.002) and fibrous appearance in the recurrent group (p = 0.002) were statistically significant. Predominant epithelium was combined respiratory and squamous epithelium in primary and recurrent groups and also in RnR group (p = 0.019), while it was squamous (p = 0.024) in RwR group. Epithelial hyperplasia was more common in primary and RnR groups. Oncocytic change, cystic dilatation, microabscess and squamous metaplasia were seen more in recurrent and RnR groups. Cytoplasmic glycogenation was more in recurrent and RwR groups. Stroma was predominantly edematous in all the groups. CONCLUSIONS: Patients with recurrence are younger and present earlier than those with primary disease. Fleshy appearance and pink/red colour of tumour, lining epithelium being squamous and cytoplasmic glycogenation could be considered as features predicting recurrence. Negative predictors of recurrence of IP include pale appearance of tumour, combined respiratory and squamous epithelium lining and squamous metaplasia.

Construct and Validation of a Three-Dimensional Physical Model for Training in Transnasal Office Procedures.

Most simulation models in rhinology are costly and are primarily meant to enhance endoscopic surgical skills. The present study aimed to construct a 3-dimensional model of the nose which is easily constructible with commonly available low cost plaster of Paris (POP) and assess its usefulness in training residents in basic transnasal procedures. A nose model was created using plaster of Paris and assessed for face and content validity by experts in rhinology while a construct validation was performed on five specified tasks by residents. All experts agreed with the resemblance of 10 of the 13 anatomical landmarks in the POP model and its utility in teaching basic transnasal procedures. There was a statistically significant difference in the time taken by I and III year residents in performing a diagnostic nasal endoscopy (p = 0.007), anterior nasal packing with polyvinyl alcohol tampon (p = 0.007), posterior nasal packing with Foley's catheter (p = 0) and nasopharyngeal swabbing (p = 0.025). This study demonstrates the construct of a low cost 3-dimensional POP model and validates its utility in training residents in routine transnasal rhinological procedures. Face and content validation showed a high degree of resemblance to human anatomy with good agreement that this model could increase resident competency. The significant difference in time taken by residents at various levels of experience in performing rhinological procedures also confirmed a reliable construct validity. The described model could be an affordable and easily constructible alternative tool to other simulation models in otorhinolaryngology residency programs especially in developing countries.

Cryptic aspergillosis: a rare entity and a diagnostic challenge.

Introduction: Cryptic aspergillosis, caused by cryptic species of Aspergillus, is increasingly reported in humans and causes significant morbidity and mortality in immunocompromised individuals. The main aim of this study was to describe the occurrence of this entity at a large tertiary care centre and analyse the challenges in identifying them in a routine diagnostic laboratory. Methods: This was a retrospective case review of all patients diagnosed with cryptic Aspergillus species from April 2019 to February 2020. The isolates were identified using conventional microbiological techniques, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI- TOF MS), 28S rRNA and internal transcribed spacer (ITS) sequencing. Results: The species identified were Aspergillus tamarii, Aspergillus lentulus and Aspergillus sydowii. Identification by MALDI- TOF MS and sequencing was concordant for all except A. sydowii, with MALDI- TOF MS misidentifying it as Aspergillus thermomutans. All isolates showed low minimum inhibitory concentrations (MICs) for the panel of antifungal drugs. Conclusion: Aspergillosis caused by cryptic Aspergillus species presents a diagnostic challenge. This study confirms the importance of molecular methods for accurate identification.

Oxygen desaturation index as alternative parameter in screening patients with severe obstructive sleep apnea.

Objectives: Assess reliability of oxygen desaturation index (ODI) as an alternative parameter to apnea hypopnea index (AHI) in screening patients with severe obstructive sleep apnea (OSA). Material and Methods: Retrospectively two-year data on demography, anthropometric features, polysomnography (PSG) parameters [AHI, ODI, minimum oxygen saturation (SpO2), mean SpO2], and Epworth sleepiness score (ESS) were collected and analyzed. Results: Study showed significant correlation of ESS with AHI, ODI, apnea-hypopnea percentage of sleep period time (AH%SPT), mean SpO2 and minimum SpO2 with highest correlation being with AHI. A Cohen's weighted Kappa analysis showed good concordance of 87.32% between AHI and ODI in classifying severity of OSA, with a significant R2 correlation of 0.84 on linear regression. An ODI>20 has a sensitivity of 96.6% and specificity of 69.6% in diagnosing severe OSA. Conclusion: Good concordance between AHI and ODI makes nocturnal oximetry a less expensive tool to confdently screen patients with severe OSA.

Characteristics of Chronic Rhinosinusitis with Nasal Polyps Based on Allergic Mucin and Fungal Elements in Patients Undergoing Revision Endoscopic Sinus Surgery.

This study sought to document the features in chronic rhinosinusitis with nasal polyp (CRSwNP) patients undergoing revision endoscopic sinus surgery (RESS), based on presence or absence of allergic mucin (AM) and fungal elements (F). A retrospective chart review of RESS cases collected Lund Mackay score (LMS), endoscopic, microbiological, histopathological, surgical and follow-up data of these patients. Patients were categorised into AM + F +, AM + F-, AM-F + and AM-F- subgroups based on the presence or absence of AM and F. The total serum IgE was significantly higher (p > 0.001) in the AM + F + subgroup. Other factors analysed including LMS, duration from previous surgery, comorbidities, degree of inflammation and disease recurrence showed no specific predilection among subgroups. Patients with a retained middle turbinate showed lesser (p = 0.04) recurrence on follow-up. Subgroups of recurrent CRSwNP showed similar characteristics and had further disease recurrence which was independent of allergic mucin and fungal elements. The presence of an intact healthy middle turbinate could reduce early disease recurrence following RESS.

Frontoethmoidal Extranasopharyngeal Angiofibroma With Orbital Pyocele.

Significance StatementExtranasopharyngeal angiofibromas (ENA) are rare vascular tumors that do not conform to the clinical characteristics of typical nasopharyngeal angiofibromas. We present the management of an angiofibroma in a rare site, within the frontal sinus with a concomitant orbital pyocele, which was completely excised via an endoscopic approach. ENAs should be considered as a differential diagnosis in patients with sinonasal mass and epistaxis. Awareness of this rare entity will avoid radical surgery thus decreasing postoperative morbidity.

Effect of Silver Nitrate Cauterisation of Nasal Mucosa on Quality-of-Life and Histology in Patients with Intractable Chronic Rhinitis.

Patients with chronic rhinitis causing intractable sneezing which is non-responsive to conventional medication require alternative therapies. The aim of the study was to ascertain the effect of topical 10% silver nitrate solution on the inferior turbinate mucosa as well as quality of life in such patients. Patients with severe chronic rhinitis who failed conventional therapy had application of 10% silver nitrate solution to inferior turbinate mucosa. The number of sneezes/day and mini Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score was noted before and 8 to 16 weeks after treatment. Pre- and post treatment turbinate biopsies were performed to assess histological changes. At baseline, 67 patients had a mean of 36.6 sneezes/day and mean mini RQLQ score of 4.0 ± 0.7. Pre-treatment biopsies showed epithelial denudation and hyalinization of basement membrane. Following 10% silver nitrate application, 64/67 (95.5%) patients showed significant reduction in number of sneezes both at 1 week (p < 0.001) and 8-16 weeks (mean = 5.5 ± 7.8; p < 0.001). Post- treatment mean global mini RQLQ score was also significantly reduced (mean = 1.3 ± 1.1; p < 0.001). A single application was sufficient in 70.1% patients. There were no complications. Squamous metaplasia (p = 0.005) and epithelial hyperplasia (p = 0.013) as well as epithelial and basement membrane restoration occurred following therapy. 10% silver nitrate solution application is an effective and safe office- based procedure which significantly reduces sneezing improves QoL with corresponding histological changes.

Rhinosporidiosis-Factors predicting disease recurrence.

BACKGROUND: Rhinosporidiosis is a chronic granulomatous disease of the nose caused by Rhinosporidium seeberi. The disease is largely non-amenable to medical therapy and shows high recurrence rates requiring patients to undergo multiple surgeries often resulting in increased morbidity. OBJECTIVE: To analyse the epidemiological, clinical, histopathological characteristics, treatment and outcome in rhinosporidiosis and to identify factors which predispose to recurrence of the disease. PATIENTS/METHODS: Retrospective analysis of data of all patients with a diagnosis of rhinosporidiosis confirmed by histopathology at a tertiary care hospital from 2015 to 2019. RESULTS: There were 42 patients, 40 males and two females, with a mean age of 37.37 years. Disease showed bilateral involvement in 17 (40.48%) patients. Nineteen (45.24%) patients had more than two sites involved at initial presentation. Most patients had nasal cavity involvement followed by nasopharynx. Among the 28 patients who had a follow-up, 12 showed recurrent disease. However, 21 patients were disease free following a revision excision. Involvement of more than two sites was an independent significant factor for recurrence. On univariate analysis, other factors which showed statistically significant odds of developing recurrence were previous surgery (p = .054), involvement of nasal septum (p = .022), middle turbinate (p = .024), nasopharynx (p = .049) and posterior pharyngeal wall (p = .05). Factors which showed significantly less likelihood of developing a recurrence included patients who had less than 12 months duration from first symptom to intervention (p = .016), involvement of less than two sites (p = .0003) and unilateral disease (p = .019). CONCLUSION: Early intervention in rhinosporidiosis especially when the disease is unilateral and involves less than two sites improves the outcome.

Risk factors associated with the mucormycosis epidemic during the COVID-19 pandemic.

This study was performed to assess the risk factors driving the epidemic of coronavirus disease 2019 (COVID-19)-associated mucormycosis (COVID-Mucor) in India that has accompanied the COVID-19 pandemic, particularly during the second wave. Risk factors were analysed among 164 participants: 132 COVID-Mucor (cases) and 32 non-COVID-Mucor (controls). Data from a prospective cohort study of mucormycosis over a period of 1 year were used. Diabetes mellitus remained a significant risk factor in both groups (97%), while uncontrolled diabetes mellitus (odds ratio (OR) 4.6; P = 0.026) and newly detected diabetes (OR 3.3; P = 0.018) were more common among the cases. Most patients with COVID-Mucor had mild COVID-19. Steroid use, often unwarranted, was highly associated with COVID-Mucor after adjusting for other risk factors (OR 28.4; P = 0.001). Serum ferritin was significantly higher (P = 0.041), while C-reactive protein was not, suggesting that alterations in iron metabolism may predispose to COVID-Mucor. Oxygen was used only in a small minority of patients with COVID-Mucor. The in-hospital mortality in both groups was low. In conclusion, the Indian COVID-Mucor epidemic has likely been driven by a convergence of interlinked risk factors: uncontrolled diabetes mellitus, unwarranted steroid use, and perhaps COVID-19 itself. Appropriate steroid use in patients with severe COVID-19 and screening and optimal control of hyperglycaemia can prevent COVID-Mucor.

Rhinofacial conidiobolomycosis: Clinical and microbiological characterisation and shift in the management of a rare disease.

BACKGROUND: Conidiobolomycosis is a rare tropical rhinofacial fungal infection which has not been well characterised. The available evidence in its management is sparse due to lack of clinical studies and the limited data on antifungal susceptibility patterns. OBJECTIVE: To analyse the clinical manifestations, antifungal treatment and outcomes of patients with conidiobolomycosis and to determine antifungal susceptibility profiles of the isolates. PATIENTS/METHODS: Retrospective analysis of data of all patients with a diagnosis of conidiobolomycosis confirmed by histopathology and culture at a tertiary care hospital from 2012 to 2019 was done. RESULTS: There were 22 patients, 21 males and one female, with a mean age of 37.1 years. Most common presenting symptom was nasal obstruction, found in 20 (90.90%) patients. Patients who presented within 12 months had a better cure rate (85%) compared to those who presented late (67%). Among the 19 patients who had a follow-up, good outcome was seen in 15 of the 17 (88.24%) patients who were on itraconazole or potassium iodide containing regimen. Of the six patients who received additional trimethoprim-sulphamethoxazole (co-trimoxazole), 67% showed good outcome with two patients showing complete cure and two patients still on treatment with significant improvement. High minimum inhibitory concentration (MIC) values were noted for azoles and amphotericin B, whereas co-trimoxazole showed lowest MIC ranges. CONCLUSION: Itraconazole and potassium iodide are reasonable first-line options for the treatment of conidiobolomycosis. Good clinical response to KI and comparatively lower MIC of co-trimoxazole are promising. Further studies are required for developing clinical breakpoints that can predict therapeutic outcomes.

Sinonasal inflammatory myofibroblastic tumour: a rare entity with diagnostic challenges.

Inflammatory myofibroblastic tumour is a rare entity causing sinonasal involvement with variable behaviour. Mimicking various benign and malignant lesions, accurate diagnosis is often clinched on histopathology complemented with appropriate immunohistochemistry markers. Surgical resection is the main treatment modality with other forms of therapy reserved for unresectable lesions. We highlight a case of dual involvement of the sinonasal region and nasal bones along with the diagnostic and treatment challenges encountered. As the nasal bones were involved, surgical resection with negative margins required cosmetic reconstruction in the same sitting. A costochondral graft helped in achieving cosmetic pleasing results with no recurrence on follow-up.

Human papilloma virus induced oropharyngeal inverted papilloma as a precursor to laryngeal papillomatosis in A 1 year old child.

Inverted papillomas are rare tumors in the pediatric population and have not been reported in children less than two years. These tumors may produce respiratory distress in patients, particularly if they ectopically occur in the airway. Human papilloma virus is one of the known etiologies for many head and neck neoplasms including inverted papillomas and squamous papillomas. We report a child who was surgically treated at fifteen months of age for inverted papilloma of the pharynx who subsequently developed squamous papilloma of the larynx which persisted as a recurrent respiratory papillomatosis. This is the first such reported case to our knowledge.

Avoiding repeated surgery in patients with acute invasive fungal sinusitis.

PURPOSE: We aimed to ascertain whether using an aggressive initial surgical protocol would reduce the need for repeated sinus surgery in patients with acute invasive fungal sinusitis (AIFS). METHODS: Patients with AIFS prospectively underwent clinicoradiological assessment followed by bilateral functional endoscopic sinus surgery (FESS) and debridement of affected tissue. Antifungal therapy was also administered. Postoperative endoscopic debridement of crusts was performed weekly in the clinic. Outcomes were compared with a historical control group who underwent multiple surgeries. RESULTS: There were 42 male and 9 female patients aged 9-68 years (mean: 42.5 years). Forty (78.4%) patients were diabetic and 17.6% had hematological malignancies. The majority (60.8%) had stage 2 or 3 disease. Partial/total maxillectomy (29.4%), orbital exenteration (7.8%) and craniotomy (2%) were also performed at a single session in 20 patients. Intra-operative sampling of all sinuses was performed. Six patients who appeared to have unilateral disease based on clinicoradiological assessment were found to have bilateral disease. Only 2 patients required revision surgery. Follow-up ranged from 3 to 24 months. The survival rate was 68.2% overall and 73.5% for diabetics alone. The difference in outcomes with a single surgery versus multiple surgeries was not significant (p = 0.09) CONCLUSION: A surgical protocol involving bilateral FESS along with debridement of visibly affected areas and antifungal therapy avoids repeated surgery in patients with AIFS with no change in outcomes. The absence of clinicoradiological involvement of the paranasal sinuses does not preclude the presence of invasive fungal disease in these sinuses.