What is the recommended treatment for fungal sinusitis?

Treatment of Fungal Sinusitis

Treatment of fungal sinusitis depends critically on the type: invasive forms require immediate aggressive surgical debridement combined with systemic antifungal therapy, while non-invasive forms are managed primarily with surgery alone or surgery plus corticosteroids. 1, 2

Classification-Based Treatment Algorithm

Invasive Fungal Sinusitis (Acute or Chronic)

Initiate triple therapy immediately: 1, 2

• Systemic antifungal therapy - start without delay 1

  • For Aspergillus species: Voriconazole as first-line therapy 1, 2
  • For mucormicosis: Liposomal amphotericin B as first-line therapy 1, 2
  • Critical caveat: Triazoles (voriconazole, itraconazole) have NO activity against mucormicosis 1

• Aggressive surgical debridement - complete removal of all necrotic sinonasal tissue 1, 2

  • Endoscopic approaches show superior survival (64%) compared to open procedures (54%) 2
  • Surgical debridement is an independent positive prognostic factor (hazard ratio 0.1) 1

• Reduce immunosuppression when medically feasible 1

  • Avoid oral corticosteroids due to additive immunosuppressive effects in invasive disease 1, 2
  • Exception: may use steroids only to reduce life-threatening edema from orbital or cerebral involvement 2

Adjunctive therapies to consider: 1

• Immune-stimulating interventions (associated with 70% reduction in 1-month mortality) 1
• Hyperbaric oxygen therapy in diabetic patients 1
• Retrobulbar transcutaneous amphotericin B injection for orbital involvement 1

Fungus Ball (Mycetoma)

Surgery alone is curative - no antifungal medications needed: 2

• Simple antrostomy for maxillary or sphenoid sinus involvement 2
• Consider antrostomy combined with inferior meatal window for better outcomes with no residual inflammation 2
• Antifungal medications are NOT indicated in the absence of tissue invasion 2
• Recurrence rate is 3-4% with long-term follow-up, requiring surveillance 2

Allergic Fungal Sinusitis

Complete surgical exenteration with mucosal preservation is primary treatment: 2

• Postoperative corticosteroid therapy is essential 2

  • Topical or systemic steroids are the mainstay of medical management 2

• Antifungal therapy role remains unproven 2

  • Anecdotal reports suggest possible benefit as adjunct therapy 2
  • One recent study showed itraconazole 200 mg orally twice daily for 3 months can provide symptomatic and radiological improvement when steroids are contraindicated or patients await surgery 3
  • However, surgery remains the definitive treatment for complete disease clearance 3

• Common causative organisms: Bipolaris, Curvularia, Aspergillus, and Dreschlera species 2

Critical Prognostic Factors in Invasive Disease

Poor prognosis indicators: 1

• Hematologic malignancy (HR=3.7) 1
• Recent chemotherapy (HR=2.3) 1
• Recent bone marrow transplant (HR=2.5) 1
• Infection with atypical fungi (HR=3.1) 1
• Aplastic anemia (20% survival) 1
• Renal/hepatic failure (24% survival) 1
• Intracranial or cavernous sinus extension (25% survival) 1
• Neutropenia (29% survival) 1

Better prognosis indicators: 1

• Diabetes (50% survival - better than other immunocompromised states) 1
• Receiving liposomal amphotericin B (60% survival) 1
• Endoscopic sinus surgery (64% survival) 1

Common Pitfalls to Avoid

• Never use antibiotics alone - fungal sinusitis requires specific antifungal or surgical management, not bacterial antibiotics 4, 2
• Do not delay surgery in invasive disease - survival depends on prompt aggressive debridement 1, 2
• Unilateral polypoid disease may mimic tumors (inverted papilloma) and requires biopsy for definitive diagnosis 2
• Continued smoking after surgery is associated with significantly worse long-term outcomes 2
• Regular endoscopic examination is essential to detect early recurrence, particularly in invasive forms 2