From the Guidelines
Chronic fungal sinusitis requires immediate treatment with systemic antifungal medications, such as voriconazole, which has been shown to be superior over amphotericin for Aspergillus species, along with surgical debridement of infected tissue. The treatment approach depends on the type of fungal sinusitis, with invasive fungal sinusitis requiring aggressive medical and surgical treatment, while allergic fungal sinusitis and fungal ball sinusitis may require a combination of medical and surgical interventions.
- Key considerations in the treatment of chronic fungal sinusitis include:
- The use of systemic antifungal medications, such as voriconazole, which has been recommended for the treatment of Aspergillus species 1
- Surgical debridement of infected tissue, which is critical for the treatment of invasive fungal rhinosinusitis 1
- The potential use of newer Azoles, which may have better bioavailability and less toxicity than traditional antifungal medications 1
- The importance of regular follow-up with an ENT specialist to monitor for recurrence and adjust treatment as needed
- The choice of antifungal medication and treatment approach should be guided by the specific type of fungal sinusitis, as well as the patient's overall health status and medical history.
- For example, voriconazole may be preferred for the treatment of Aspergillus species, while amphotericin B may be used in other cases, with a starting dose of 0.5-1.0 mg/kg/day 1.
- Additionally, the use of topical or systemic antifungals, such as amphotericin B, may be considered in certain cases, with transcutaneous retrobulbar injection of amphotericin B having been reported as a potential treatment option 1.
From the Research
Definition and Classification
- Chronic fungal sinusitis is a rare disease that can be divided into acute fulminant, chronic, and granulomatous invasive fungal sinusitis 2
- Chronic invasive fungal sinusitis (CIFS) is characterized by mucosal and submucosal infiltration of mycotic organisms and angio-centric extension into orbital and intracranial structures 3
- CIFS can be further classified into chronic granulomatous invasive fungal sinusitis (CGFS) and non-granulomatous invasive fungal sinusitis 4, 5
Treatment Options
- The conventional treatment for CIFS is radical surgery combined with systemic amphotericin B administration, but this approach has a poor prognosis and unestablished treatment options 2
- Voriconazole has been shown to be an effective treatment modality for CIFS, with significant improvement in clinical response and reduction in objective parameters compared to itraconazole and amphotericin B 3, 4, 5
- Surgery followed by itraconazole or voriconazole is recommended for stage 1 and 2 disease, while voriconazole is recommended for stage 3 disease 4
- Endoscopic debridement combined with long-term oral voriconazole has been shown to be an effective treatment strategy for CIFS 5
Diagnosis
- The diagnosis of CIFS relies chiefly on identification of invasive fungi on histology, but negative histopathologic findings can pose a diagnostic challenge 6
- Fungal DNA detection through polymerase chain reaction (PCR) can be an important complement to histology and culture in the diagnosis of CIFS 6
- Imaging findings, such as thickening of sinus mucosa or invasion of the orbit and skull base, can also aid in diagnosis 5