eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Sinusitis, Fungal: Treatment

Author: Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University
Contributor Information and Disclosures

Updated: Apr 22, 2009

Treatment

Medical Therapy

The treatment of choice for all types of fungal sinusitis is surgical. Medical treatment depends on the type of infection and the presence of invasion.

Allergic fungal sinusitis

The treatment of choice is generally surgery. Systemic steroids may be indicated once surgery is performed and the diagnosis is confirmed. Some authors suggest a low dose of prednisone (0.5 mg/kg) in a tapering dose with alternate-day dosage over a 3-month period. Topical nasal steroids are helpful postoperatively. Aggressive nasal salt-water washes are recommended. Immune therapy for specific allergens is controversial, even though some reports suggest benefit from this treatment. Systemic antifungals are not indicated in the absence of invasion.

Sinus mycetoma

The recommended treatment is surgical. Once the fungus ball is removed, no further medical treatment is indicated, except for the underlying condition. No antifungal treatment is necessary.

Chronic invasive fungal sinusitis

Surgical treatment is mandatory. Initiate medical treatment with systemic antifungals once invasion is diagnosed. Amphotericin B (2 g/d) is recommended; this can be replaced by ketoconazole or itraconazole once the disease is under control.

Acute invasive fungal sinusitis

Emergent treatment is necessary once this condition is suspected. Initiate systemic antifungal treatment after surgical debridement. High doses of amphotericin B (1-1.5 mg/kg/d) are recommended. Oral itraconazole (400 mg/d) can replace amphotericin B once the acute stage has passed. Treatment of the underlying immune deficiency, if possible, is desirable.

Chronic granulomatous fungal sinusitis

Surgical debridement is the mainstay of treatment, followed by systemic antifungal medications. Recurrence of this condition is rare.

Surgical Therapy

Allergic fungal sinusitis

Surgery is generally considered the treatment of choice. Goals of surgical therapy are conservative debridement of the allergic mucin and polyps (if present) from the involved sinuses and restoration of sinus aeration. Goals may be achieved endoscopically if possible. An external approach can be considered if the lesion is not accessible endoscopically. Adequate ventilation of the sinus is essential to prevent relapse or recurrence of the disease once the disease is exenterated.

Sinus mycetoma

Surgical removal of the fungus ball with aeration of the sinus is the only requirement. Once this is accomplished, no further medical treatment is indicated, except for the underlying condition. Endoscopic lesion removal can be performed when the lesion is accessible. Consider an external approach in patients in whom the mycetoma cannot be removed endoscopically.

Acute invasive fungal sinusitis

Perform emergency surgery once this condition is suspected. Perform radical debridement of the necrotic tissue until normal tissue is reached. Often, debridement is achieved via external approaches. In some cases, the skull-base team should be involved.

Chronic invasive fungal sinusitis

This condition is usually less aggressive than the acute stage. Surgical debridement is still warranted and can be approached endoscopically in some patients. Consider an external approach when adequate debridement cannot be achieved endoscopically.

Chronic granulomatous fungal sinusitis

Surgical debridement is the treatment of choice. Endoscopic and external approaches can be considered.

Follow-up

Allergic fungal sinusitis

Long-term follow-up care is required for maintenance of the sinus cavities; this may be achieved via endoscopic examination and debridement in the office. A short course of systemic steroids may be readministered if any signs of relapse or recurrence are seen. Surgical debridement may be necessary if systemic steroids fail to control the disease.

Sinus mycetoma

Long-term follow-up care is not required once the lesions are healed and patency of the sinuses is maintained.

Acute invasive fungal sinusitis

This condition is rare and is usually associated with a high mortality rate. Survivors may have facial deformities and require long-term follow-up care by several specialists, including head and neck surgeons, infectious-disease specialists, and immunodeficiency specialists.

Chronic invasive fungal sinusitis

This condition tends to recur. Therefore, long-term follow-up care is recommended.

Chronic granulomatous fungal sinusitis

Experience with this condition is limited. Prognosis is good, but a tendency toward recurrence exists.

Complications

Allergic fungal sinusitis

Erosion into the adjacent structures may occur if the condition is left untreated. Erosion is most often observed in individuals who present with proptosis. Sinusitis symptoms worsen and do not respond to routine antimicrobial therapy.

Sinus mycetoma

Fungus balls, if left untreated, cause worsening of sinusitis symptoms, with the potential for complicated sinusitis. This may predispose the patient to complications, such as those involving the orbit and CNS.

Acute invasive fungal sinusitis

Initiate emergency treatment once this condition is suspected. This is a rapidly progressive disease that invades adjacent structures, causing tissue damage and necrosis. Cavernous sinus thrombosis and invasion of the CNS are common and carry a mortality rate of 50-80%.

Chronic invasive fungal sinusitis

Invasion into adjacent structures is not as common as in the acute type. However, erosion into the orbit or CNS is likely if the disease is left untreated.

Chronic granulomatous fungal sinusitis

Erosion into the adjacent structures (eg, orbit, CNS) is likely. Initiate aggressive therapy to avoid erosion.

More on Sinusitis, Fungal

Overview: Sinusitis, Fungal
Workup: Sinusitis, Fungal
Treatment: Sinusitis, Fungal
Follow-up: Sinusitis, Fungal
Multimedia: Sinusitis, Fungal
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Hussain S, Salahuddin N, Ahmad I, Salahuddin I, Jooma R. Rhinocerebral invasive mycosis: occurrence in immunocompetent individuals. Eur J Radiol. Jul 1995;20(2):151-5. [Medline].

  2. Scharf JL, Soliman AM. Chronic rhizopus invasive fungal rhinosinusitis in an immunocompetent host. Laryngoscope. Sep 2004;114(9):1533-5. [Medline].

  3. Siddiqui AA, Shah AA, Bashir SH. Craniocerebral aspergillosis of sinonasal origin in immunocompetent patients: clinical spectrum and outcome in 25 cases. Neurosurgery. Sep 2004;55(3):602-11; discussion 611-3. [Medline].

  4. Pant H, Schembri MA, Wormald PJ, Macardle PJ. IgE-mediated fungal allergy in allergic fungal sinusitis. Laryngoscope. Apr 8 2009;[Medline].

  5. Gamba JL, Woodruff WW, Djang WT, Yeates AE. Craniofacial mucormycosis: assessment with CT. Radiology. Jul 1986;160(1):207-12. [Medline].

  6. Manning SC, Merkel M, Kriesel K, Vuitch F, Marple B. Computed tomography and magnetic resonance diagnosis of allergic fungal sinusitis. Laryngoscope. Feb 1997;107(2):170-6. [Medline].

  7. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. Aug 2008;122(2 Suppl):S1-84. [Medline].

  8. Anselmo-Lima WT, Lopes RP, Valera FC, Demarco RC. Invasive fungal rhinosinusitis in immunocompromised patients. Rhinology. Sep 2004;42(3):141-4. [Medline].

  9. Corey JP, Romberger CF, Shaw GY. Fungal diseases of the sinuses. Otolaryngol Head Neck Surg. Dec 1990;103(6):1012-5. [Medline].

  10. deShazo RD. Fungal sinusitis. Am J Med Sci. Jul 1998;316(1):39-45. [Medline].

  11. deShazo RD, O'Brien M, Chapin K, Soto-Aguilar M, Gardner L, Swain R. A new classification and diagnostic criteria for invasive fungal sinusitis. Arch Otolaryngol Head Neck Surg. Nov 1997;123(11):1181-8. [Medline].

  12. Gillespie MB, O'Malley BW Jr, Francis HW. An approach to fulminant invasive fungal rhinosinusitis in the immunocompromised host. Arch Otolaryngol Head Neck Surg. May 1998;124(5):520-6. [Medline].

  13. Gosepath J, Mann WJ. Role of fungus in eosinophilic sinusitis. Curr Opin Otolaryngol Head Neck Surg. Feb 2005;13(1):9-13. [Medline].

  14. Jahrsdoerfer RA, Ejercito VS, Johns MM, Cantrell RW, Sydnor JB. Aspergillosis of the nose and paranasal sinuses. Am J Otolaryngol. Fall 1979;1(1):6-14. [Medline].

  15. Lansford BK, Bower CM, Seibert RW. Invasive fungal sinusitis in the immunocompromised pediatric patient. Ear Nose Throat J. Aug 1995;74(8):566-73. [Medline].

  16. Ochi JW, Harris JP, Feldman JI, Press GA. Rhinocerebral mucormycosis: results of aggressive surgical debridement and amphotericin B. Laryngoscope. Dec 1988;98(12):1339-42. [Medline].

  17. Press GA, Weindling SM, Hesselink JR, Ochi JW, Harris JP. Rhinocerebral mucormycosis: MR manifestations. J Comput Assist Tomogr. Sep-Oct 1988;12(5):744-9. [Medline].

  18. Sasama J, Sherris DA, Shin SH, Kephart GM, Kern EB, Ponikau JU. New paradigm for the roles of fungi and eosinophils in chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg. Feb 2005;13(1):2-8. [Medline].

  19. Schubert MS, Hutcheson PS, Graff RJ, Santiago L, Slavin RG. HLA-DQB1 *03 in allergic fungal sinusitis and other chronic hypertrophic rhinosinusitis disorders. J Allergy Clin Immunol. Dec 2004;114(6):1376-83. [Medline].

  20. Shin SH, Ponikau JU, Sherris DA, et al. Chronic rhinosinusitis: an enhanced immune response to ubiquitous airborne fungi. J Allergy Clin Immunol. Dec 2004;114(6):1369-75. [Medline].

  21. Sohail MA, Al Khabori MJ, Hyder J, Verma A. Allergic fungal sinusitis: can we predict the recurrence?. Otolaryngol Head Neck Surg. Nov 2004;131(5):704-10. [Medline].

  22. Washburn RG. Fungal sinusitis. Curr Clin Top Infect Dis. 1998;18:60-74. [Medline].

  23. Wise SK, Venkatraman G, Wise JC, DelGaudio JM. Ethnic and gender differences in bone erosion in allergic fungal sinusitis. Am J Rhinol. Nov-Dec 2004;18(6):397-404. [Medline].

[ CLOSE WINDOW ]

Further Reading

In 2008, the guidelines for the diagnosis and management of rhinitis were updated. 7

[ CLOSE WINDOW ]

Keywords

allergic fungal sinusitis, fungal sinusitis, indolent fungal sinusitis, mucormycosis, sinus fungus ball, sinus mycetoma, sinus infection, aspergillosis, Aspergillus species infection, Mucor species infection, Curvularia lunata infection, Aspergillus fumigatus infection, C lunata infection, A fumigatus infection, Bipolaris species infection, Drechslera species infection, dematiaceous fungi infection, Rhizopus species infection, Rhizomucor species infection, Absidia species infection, Cunninghamella species infection, Mortierella species infection, Saksenaea species infection, Apophysomyces species infection, Aspergillus flavus infection, A flavus infection

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University
Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Rhinologic Society
Disclosure: Nothing to disclose.

Medical Editor

Lanny Garth Close, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons
Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.