What is the treatment approach for fungal sinusitis?

Treatment Approach for Fungal Sinusitis

The treatment of fungal sinusitis requires surgical intervention as the primary approach, with specific medical therapy determined by the type of fungal infection present. 1

Types of Fungal Sinusitis and Their Treatment

Fungus Ball (Fungal Mycetoma)

• Surgical removal through simple antrostomy is the mainstay of treatment for fungus balls, which typically occur in the maxillary or sphenoid sinuses 1
• More extensive procedures may be needed in certain cases - when an antrostomy was combined with an inferior meatal window, better outcomes were observed with no residual inflammation 1
• Antifungal medications are not indicated in the absence of invasion 1
• Recurrence rates of 3-4% have been reported with longer follow-up, suggesting the need for surveillance 1

Allergic Fungal Sinusitis

• Complete surgical exenteration with mucosal preservation is the primary treatment 1
• Postoperative steroid therapy is essential for management 1
• The role of postoperative antifungal therapy remains unproven, though anecdotal reports suggest it might be beneficial as an adjunct 1
• Common causative fungi include Bipolaris, Curvularia, Aspergillus, and Dreschlera species 1

Invasive Fungal Sinusitis

• Requires aggressive combined approach with both surgical and medical interventions 1, 2

• Surgical management:

  • Aggressive debridement of necrotic sinonasal tissue is essential 1
  • Endoscopic surgical approaches have shown better survival rates (64%) compared to open procedures (54%) 1
  • Complete removal of all infected and necrotic tissue is critical 1, 2

• Medical management:

  • Systemic antifungal therapy is mandatory 1
  • Liposomal amphotericin B is recommended as first-line therapy 1, 2
  • Voriconazole may be superior for Aspergillus species 1
  • Newer azoles may offer better bioavailability and less toxicity 1
  • Reversal of underlying immunosuppression when possible 2

• Adjunctive therapies:

  • Transcutaneous retrobulbar injection of amphotericin B (1-1.5ml at concentrations of 1-3.5mg/ml) may be beneficial in cases with orbital involvement 1
  • Immune stimulating interventions have been associated with 70% reduction in mortality at one month 1
  • Hyperbaric oxygen therapy may be beneficial, particularly in diabetic patients 1

Special Considerations

Patient Factors Affecting Treatment Decisions

• Immunocompromised status significantly impacts treatment approach and prognosis 2
• Diabetic patients have better survival rates (50%) compared to those with aplastic anemia (20%), renal/hepatic failure (24%), or neutropenia (29%) 1
• Patients with hematologic malignancies have worse prognosis (hazard ratio 3.7) 1
• Recent chemotherapy (HR=2.3) and bone marrow transplant (HR=2.5) are associated with worse outcomes 1

Follow-up and Monitoring

• Regular endoscopic examination is recommended to detect early recurrence, especially in invasive forms 3
• CT imaging is the gold standard for evaluation of sinusitis, with MRI better for assessing orbital and intracranial complications 3
• Histopathological examination remains essential for definitive diagnosis and classification 3

Treatment Pitfalls and Caveats

• Oral corticosteroids are generally avoided in invasive fungal disease due to potential additive immunosuppressive effects, except when needed to reduce edema associated with orbital or cerebral involvement 1
• Delayed diagnosis and treatment of invasive fungal sinusitis is associated with high mortality rates, approaching 50% despite advances in management 2
• Fungal sinusitis that appears as unilateral polypoid disease may mimic tumors (e.g., inverted papilloma) and should be biopsied 1
• Continued smoking after surgery is associated with significantly worse long-term outcomes 1