Does a fungal ball in the sinus need to be treated?

Treatment of Sinus Fungal Ball

Yes, a fungal ball in the sinus requires surgical treatment, even if asymptomatic, because the natural history includes persistent low-grade inflammation, progressive expansile changes, and potential serious complications including orbital and intracranial infections. 1

Why Treatment is Mandatory

The European Position Paper on Rhinosinusitis (2020) explicitly states that asymptomatic disease does not mean that surgery should be avoided 1. This recommendation is based on several critical morbidity and mortality concerns:

Risk of Serious Complications

• 16% of sphenoid fungal balls develop orbital infective complications, particularly when bone wall architecture is lost 1
• Intracranial infective complications can occur, representing life-threatening morbidity 1
• The natural history demonstrates that low-grade inflammation occurs persistently, expansile changes develop in the majority of cases, and infective complications can arise even in seemingly indolent disease 1

Differential Diagnosis Concerns

• Isolated maxillary or sphenoid sinus opacification carries an 18% risk of neoplasia and 7-10% risk of malignancy 1
• Clinicians should maintain a low threshold for early surgical intervention given the high incidence of neoplasia in single sinus disease 1

Surgical Approach

Surgery is the primary and mainstay treatment for fungal balls 1. The surgical strategy should be:

Standard Procedure

• Simple antrostomy is the most commonly recommended initial approach 1, 2
• Complete removal of all fungal debris through wide sinusotomy is essential 3
• Endoscopic surgery is safe and effective with no recurrence observed in properly performed procedures 3

Enhanced Procedures for Better Outcomes

• Combining antrostomy with an inferior meatal window results in superior outcomes, with 0% residual inflammation or debris compared to 50% inflammation and 14% residual debris with simple antrostomy alone 1
• Medial maxillectomy should be considered for maxillary fungal balls in smaller contracted sinuses or when there are concerns about poor sinus function 1

Recurrence Rates

• Long-term follow-up studies report recurrence rates of 3-4% with adequate surgical removal 1, 2
• Persistent sinus dysfunction with mucostasis occurs in up to 18% of cases after simple antrostomy 1, 4

Medical Therapy Has No Role

The guidelines are unequivocal about medical management:

• Antifungal medications (topical or systemic) are not indicated in the absence of tissue invasion 1, 2
• Oral corticosteroids have no proven role, though sometimes used perioperatively 1
• Topical corticosteroids are not supported by data, though commonly given postoperatively 1
• Immunotherapy plays no role in fungal ball management 1

Critical Pitfalls to Avoid

Do Not Observe Conservatively

• The misconception that asymptomatic fungal balls can be watched is dangerous given the 16% risk of orbital complications and potential for intracranial extension 1
• Even though fungal balls may follow an indolent course for years, progressive inflammation and bone erosion occur 1

Ensure Adequate Surgical Clearance

• Simple antrostomy alone may be insufficient, with 50% showing persistent inflammation 1
• Consider more extensive procedures (inferior meatal window, medial maxillectomy) for optimal outcomes 1

Rule Out Malignancy

• Always maintain high suspicion for neoplasia in isolated sinus opacification, as 7-10% represent malignancy 1
• Histopathological examination is mandatory to confirm diagnosis 3, 5

Follow-Up Strategy

• Endoscopic examination every 2 months during the first postoperative year, then every 6 months 3
• Monitor for mucostasis, which occurs in 18-39% of patients at 3 months and may indicate need for revision surgery 4
• Patients with persistent mucostasis have higher inflammation scores and greater need for further surgery 4