What is the treatment for fungal sinusitis?

Treatment of Fungal Sinusitis

Surgery is the primary treatment for fungal sinusitis, with the specific approach determined by the type of fungal sinusitis present. 1, 2

Types of Fungal Sinusitis and Their Treatment

1. Non-Invasive Fungal Sinusitis

Fungal Ball (Mycetoma)

• Surgical Management:

  • Complete surgical removal via endoscopic sinus surgery is the mainstay of treatment 1
  • Simple antrostomy is commonly used, but may be insufficient in some cases 1
  • Combined approach with inferior meatal window shows better outcomes with less residual inflammation (0% vs 50%) 1
  • Medial maxillectomy may be considered for smaller contracted sinuses 1

• Medical Management:

  • Antifungal medications are NOT indicated in the absence of invasion 1
  • Perioperative care may include:
    • Saline irrigations
    • Intranasal corticosteroids
    • Occasional use of antibiotics
  • Note: While these adjunctive treatments are commonly used, no published data supports their efficacy 1

Allergic Fungal Sinusitis

• Surgical Management:

  • Complete removal of allergic mucin and polyps via endoscopic sinus surgery 2, 3

• Medical Management:

  • Postoperative oral corticosteroids to reduce disease activity 3
  • Aggressive allergy management including allergen immunotherapy 3
  • Monitor total serum IgE levels to predict disease recurrence 3

2. Invasive Fungal Sinusitis

Acute Invasive Fungal Sinusitis

• Surgical Management:

  • Aggressive surgical debridement of all necrotic tissue 1, 2, 4
  • Early surgical intervention is critical - delay >30 days predicts poorer outcomes 1
  • Intraoperative frozen section has excellent positive predictive value (100%) but negative predictive value is only 70% 1

• Medical Management:

  • First-line antifungal therapy: Liposomal amphotericin B 2, 4

    • Early initiation is critical for survival 1

  • For Aspergillus species: Voriconazole is preferred 1, 2

    • Recommended for CNS aspergillosis with favorable responses in 35% of cases 1
    • Loading dose: 70mg on day 1, followed by 50mg daily 5
    • Duration based on severity of underlying disease and clinical response 5

  • For refractory cases: Caspofungin may be considered 1, 5

  • Adjunctive measures:

    • Correction of underlying conditions (especially diabetes control) 2
    • Immune stimulating interventions (associated with 70% reduction in mortality) 1
    • Hyperbaric oxygen therapy (particularly beneficial for diabetic patients) 1, 2

Important Considerations

• Diagnostic accuracy: Proper identification of the type of fungal sinusitis is crucial as treatment approaches differ significantly 6, 7

• Mortality rates: Despite treatment, invasive fungal sinusitis has high mortality (50-60%) 2, 4

• Orbital involvement: Present in 50-60% of invasive cases at diagnosis; may require specialized management 1

• Follow-up: Regular monitoring is essential, especially for allergic fungal sinusitis, which requires medical/surgical co-management 3

• Recurrence rates: Fungal ball recurrence reported in 3.2-4% of cases with longer follow-up 1

• Pitfalls to avoid:

  • Delaying surgical intervention in invasive disease
  • Failing to identify the causative fungal species (especially important when choosing between amphotericin B and voriconazole)
  • Overlooking the need for immune status correction in invasive disease
  • Using antifungals unnecessarily in non-invasive disease without evidence of invasion

By understanding the specific type of fungal sinusitis and implementing the appropriate surgical and medical interventions promptly, outcomes can be significantly improved for patients with this challenging condition.