What are the treatment options for sinusitis with a mycetoma (fungal ball)?

From the Guidelines

Sinusitis with mycetoma requires a combined treatment approach of surgical intervention and antifungal therapy, with surgical removal of the fungal ball being the primary approach, as recommended by the Infectious Diseases Society of America in 2016 1. The primary goal of treatment is to remove the fungal mass and restore normal sinus drainage, which can be achieved through functional endoscopic sinus surgery (FESS).

• Surgical debridement or removal of the fungal ball (mycetoma) is necessary because antifungal medications alone cannot effectively penetrate the dense fungal mass.
• Following surgery, patients should receive systemic antifungal therapy, typically with voriconazole or a lipid formulation of AmB, as recommended by the guidelines 1.
• The treatment regimen should include enlargement of the sinus ostomy to improve drainage and prevent recurrence, as suggested by the guidelines 1.
• Regular follow-up with nasal endoscopy every 1-3 months is essential to monitor for recurrence, and patients with underlying immunocompromise require particularly close monitoring and may need more aggressive or prolonged therapy.
• The use of saline nasal irrigation (240-480 mL twice daily) post-operatively can help maintain sinus patency and promote healing.
• The treatment approach should be individualized based on the severity of the disease, the patient's underlying health status, and the presence of any underlying immunocompromise.

From the Research

Definition and Classification of Mycetoma

• Mycetoma is a localized chronic, suppurative, and deforming granulomatous infection seen in tropical and subtropical areas 2.
• It is a disorder of subcutaneous tissue, skin, and bones, mainly of feet, characterized by a triad of localized swelling, underlying sinus tracts, and production of grains or granules.
• Etiological classification divides it into eumycetoma caused by fungus, and actinomycetoma caused by bacteria.

Sinus Mycetoma

• Sinus mycetoma is a noninvasive syndrome of fungal infection in the sinuses 3.
• Proposed diagnostic criteria for sinus mycetoma include specific histopathologic findings and exclusion of patients with invasive fungal sinusitis.
• Clinical features of sinus mycetoma include frequent atopy, nasal polyps, calcification within the sinus on computed tomography, and an excellent response to surgical treatment.

Treatment of Sinus Mycetoma

• Surgical removal of the sinus fungal masses to ensure drainage and aeration is the recommended treatment for Aspergillus mycetoma of the maxillary sinus 4.
• Endoscopic sinus surgery (ESS) with middle meatal antrostomy is considered the gold standard surgical technique.
• General or local antifungal drugs are not indicated, but may be used in the treatment of invasive fungal sinusitis 5.
• Comparison of efficacy of amphotericin B and itraconazole in chronic invasive fungal sinusitis showed that both drugs are equally efficacious, but itraconazole has fewer side effects 5.

Antifungal Susceptibility Testing

• Antifungal susceptibility testing (AFST) is used to determine the association between AFST results and in vivo therapeutic response in patients with fungal rhinosinusitis 6.
• The results of AFST may not always correlate with clinical outcomes, and therapeutic complications can confound analysis.
• Azoles are considered the drug of choice for Aspergillus infections, while amphotericin B is used for Rhizopus infections.