From the Guidelines
The treatment for a fungal ball, also known as a mycetoma or aspergilloma, typically involves surgical removal of the mass, as recommended by the Infectious Diseases Society of America 1.
Treatment Overview
For pulmonary fungal balls, surgical resection through procedures like lobectomy or segmentectomy is the definitive treatment, especially for patients with symptoms like hemoptysis (coughing up blood).
- Surgical removal is preferred because fungal balls are localized masses of fungal hyphae that grow within a pre-existing cavity without invading surrounding tissues.
- For sinus fungal balls, endoscopic sinus surgery is performed to physically remove the fungal material and restore sinus drainage.
- Unlike other fungal infections, antifungal medications like voriconazole or amphotericin B are generally not effective for fungal balls because the dense fungal mass has poor drug penetration and contains mostly non-viable fungi.
Specific Treatment Recommendations
- Surgical removal alone can be used to treat Aspergillus fungal ball of the paranasal sinus 1.
- In some cases where surgery isn't possible due to poor lung function or other contraindications, observation may be appropriate for asymptomatic patients.
- Following surgery, patients should be monitored for recurrence, though this is uncommon when the fungal material is completely removed.
- For patients with chronic pulmonary aspergillosis, long-term oral antifungal therapy is recommended to improve overall health status and respiratory symptoms, arrest haemoptysis and prevent progression 1.
- Voriconazole is preferred for the treatment of chronic necrotizing pulmonary aspergillosis and patients with fungal balls to minimize the risk of resistance 1.
Key Considerations
- The diagnosis of fungal ball requires a combination of characteristics, including one or more cavities with or without a fungal ball present or nodules on thoracic imaging, direct evidence of Aspergillus infection, and exclusion of alternative diagnoses 1.
- Patients with single Aspergillus nodules only need antifungal therapy if not fully resected, but if multiple, they may benefit from antifungal treatment and require careful follow-up 1.
From the Research
Treatment Options for Fungal Ball
- Surgical treatment is currently the mainstay of treatment for aspergilloma, particularly in cases of hemoptysis, and even in asymptomatic patients, if lung function is not severely compromised 2
- Non-surgical treatment options exist for patients who are poor surgical candidates, including systemic azoles, which are effective in approximately 50-80% of patients 3
- Alternative options to surgery include intracavitary instillation or endobronchial administration of antifungal medication, as well as direct transbronchial aspergilloma removal 3
- Bronchial artery embolization and radiotherapy are options to manage hemoptysis until definite eradication of the aspergilloma 3, 2
Surgical Management
- Surgery is very effective in controlling and preventing hemoptysis in patients who have pulmonary cavity associated with fungus ball 4
- Elective surgery and formal pulmonary resection may be the proper option for low-risk patients 4
- Cavernostomy with transposition of muscle flap may be suitable for patients who have poor pulmonary reserve 4
Treatment of Fungal Ball in the Sinuses
- Surgical treatment, usually through an endonasal endoscopic approach, is curative for fungus ball of the paranasal sinuses 5
- The diagnosis is usually suspected on imaging studies, and clinical presentation is non-specific 5