Fungal Sinusitis Treatment & Management

Updated: Mar 17, 2020
  • Author: Hassan H Ramadan, MD, MSc, FACS, FARS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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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.

A study by Mehta et al suggested that itraconazole may be as effective as amphotericin B in the treatment of chronic invasive fungal sinusitis. In a prospective, randomized, unblinded study of 26 immunocompetent patients, one group (10 patients) was treated with amphotericin B and the other (16 patients) with itraconazole. A complete cure was achieved in two patients in the amphotericin-B group and five in the itraconazole group, while four amphotericin-B patients and seven itraconazole patients experienced persistent disease, and one amphotericin-B patient and three itraconazole patients had relapses. In addition, three patients died, and one was lost to follow-up. Based on relative risk analysis, the investigators concluded that itraconazole and amphotericin B worked equally well against chronic invasive fungal sinusitis. [17]

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.

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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.

A retrospective study by Masterson et al found that in terms of treatment with surgical (endoscopic sinus surgery) and targeted medical intervention, quality-of-life benefits were more prolonged in patients with allergic fungal rhinosinusitis than in those with chronic rhinosinusitis without nasal polyposis (CRSsNP) at 9- and 12-month follow-up (over a 12-month follow-up period). The study, which included 154 patients with chronic rhinosinusitis with nasal polyposis, 72 patients with CRSsNP, and 24 patients with allergic fungal rhinosinusitis, measured quality of life using the 22-item Sino-nasal Outcome Test (SNOT-22). [18]

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.

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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.

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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.

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Outcome and Prognosis

Allergic fungal sinusitis

This disorder carries a good prognosis following adequate surgical debridement and aeration of the sinuses. Close follow-up care is important. Long-term use of topical steroids controls relapses. Short-term systemic steroids may be required when relapses occur.

Sinus mycetoma

This condition has an excellent prognosis once the fungus ball is removed and adequate aeration of the sinus is restored. No long-term follow-up care is required for most patients.

Acute invasive fungal sinusitis

This condition carries a poor prognosis. Mortality rate is reported at 50%, even with aggressive surgical and medical treatment. Relapses are common during subsequent episodes of neutropenia. Treatment with systemic antifungals as prophylaxis is indicated in cases of neutropenia.

A retrospective study by Green et al of 14 immunocompromised pediatric patients with invasive fungal sinusitis indicated that while absolute neutrophil count was a significant prognostic factor in these children, patient age and gender, cause of immunodeficiency, and fungal agent were not. [19]

A literature review by Smith et al suggested presentation with facial pain to be a negative predictor of overall mortality (odds ratio = 0.296) in pediatric patients with invasive fungal sinusitis. [20]

Chronic invasive fungal sinusitis

Good prognosis has been noted in patients who receive a prolonged course of systemic antifungals. Patients who receive shorter courses of systemic antifungals have more relapses, thereby requiring further treatment.

Chronic granulomatous fungal sinusitis

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

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