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September 2011 Otologic, Head & Neck Newsletter >>
Targeted Review: Fungal Sinus Infections
There are three distinct types of fungal infection that involve the paranasal sinuses: invasive fungal sinusitis, allergic fungal sinusitis, and sinus mycetoma.
Invasive Fungal Sinusitis
Invasive fungal sinusitis occurs in people who are immunocompromised. Immunocompromise can include prior organ transplant or chronic steroid therapy.
Early symptoms include:
Late symptoms include:
Invasive fungal sinusitis can progress within hours to days and lead to intra-orbital and intra-cranial complications. A nasal exam shows insensate and non-viable mucosa. Treatment includes wide surgical debridement and intravenous antifungal therapy. A high index of suspicion, early diagnosis, and early intervention is necessary to ensure survival.
Allergic Fungal Sinusitis
Allergic fungal sinusitis is a hypersensitivity reaction to the presence of inhaled fungal particles – a similar process can affect the lungs and is called allergic bronchopulmonary aspergillosis.
Early symptoms include:
Allergic fungal sinusitis progresses over months and can lead to erosion of the bone between the sinuses, orbit, and brain. The nasal exam shows extensive polyps blocking the nasal airway. Treatment includes surgical debridement and use of steroids to decrease inflammation; oral antifungal agents are sometimes also utilized. Allergic fungal sinusitis is a chronic condition that often lasts for years.
Fungal mycetoma affects a single sinus (maxillary or sinus) in an immunocompetent person. A mycetoma may cause no symptoms and may be found incidentally on an imaging study, or may cause symptoms of acute bacterial sinusitis due to bacterial super-infection (nasal congestion, purulent nasal drainage, and facial pain.) Nasal exam may be either normal or show purulent drainage from the involved sinus. Treatment is by surgical debridement and can be performed on an elective basis. A sinus mycetoma can be present for months to years.
Chronic sinusitis is a very common condition while fungal sinus infections are very uncommon. One myth which may be dispelled is that all people with chronic sinusitis actually have a fungal sinus infection and should be treated with antifungal therapy – such is not the case. The three types of fungal sinusitis can be differentiated from chronic sinusitis and from each other by their context, symptoms, exam and image findings.