Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Fungal rhinosinusitis

INTRODUCTION

Fungal rhinosinusitis encompasses a wide variety of fungal infections that range from merely irritating to rapidly fatal. Fungal colonization of the upper and lower airways is a common condition, since fungal spores are constantly inhaled into the sinuses and lungs. However, colonization is distinct from infection, and most colonized patients do not become ill with fungal infections. "Fungal rhinosinusitis" is the most appropriate term to describe fungal infection of the paranasal sinuses since concomitant involvement of the nasal cavity is seen in most cases [1].

Fungal colonization, as well as the pathophysiology, clinical manifestation, diagnosis, and treatment of invasive fungal rhinosinusitis will be discussed here. An additional disorder, which involves a hypersensitivity response to colonizing fungi, is called allergic fungal rhinosinusitis and is reviewed separately. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis", section on 'Allergic fungal rhinosinusitis'.)

FUNGAL COLONIZATION

Patients with anatomic abnormalities of the paranasal sinuses that impair drainage, such as nasal polyps or chronic inflammatory states, are vulnerable to fungal colonization in these areas. Areas of mucosal injury may cause pooling of mucus and subsequent colonization by fungus. However, these abnormalities are generally of no clinical importance. Aspergillus species are the most common colonizers of the sinuses, but many other species are also reported [2]. Generally, in chronic rhinosinusitis the microbiome does not include fungi, but fungi are present in a small subset of patients, particularly those with polyps and/or recent use of antibacterial agents [3].

Fungus balls — Fungal hyphae can become intertwined in dense collections and form fungus balls if there is obstruction of the paranasal sinuses [2,4]. Patients usually present with symptoms of chronic rhinosinusitis and involvement of only one sinus cavity. Computed tomography (CT) often shows a metal-dense spot within the fungus ball, and this finding was reported in 72 percent of cases in one series of 160 patients [2,5]. There may be mild sclerosis of the surrounding bone [2,4]. Surgery is required to correct the obstruction and to extract the fungus ball [2,6-8]. Recurrence after surgical removal is uncommon [2]. Glucocorticoids and antifungal agents do not offer clear benefit [2].

INVASIVE FUNGAL SINUSITIS

The marked rise in the number of immunocompromised patients has led to an increase in unusual manifestations of aggressive fungal infections. Invasive rhinosinusitis is one such form of infection that appears to be increasing in frequency. Although invasive fungal rhinosinusitis can be seen in apparently immunocompetent patients, the majority of cases involve patients with some form of immunosuppression.

           

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jul 2014. | This topic last updated: Mar 14, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Chakrabarti A, Denning DW, Ferguson BJ, et al. Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Laryngoscope 2009; 119:1809.
  2. Nicolai P, Lombardi D, Tomenzoli D, et al. Fungus ball of the paranasal sinuses: experience in 160 patients treated with endoscopic surgery. Laryngoscope 2009; 119:2275.
  3. Boase S, Foreman A, Cleland E, et al. The microbiome of chronic rhinosinusitis: culture, molecular diagnostics and biofilm detection. BMC Infect Dis 2013; 13:210.
  4. Waitzman AA, Birt BD. Fungal sinusitis. J Otolaryngol 1994; 23:244.
  5. Grosjean P, Weber R. Fungus balls of the paranasal sinuses: a review. Eur Arch Otorhinolaryngol 2007; 264:461.
  6. Lee KC. Clinical features of the paranasal sinus fungus ball. J Otolaryngol 2007; 36:270.
  7. Dufour X, Kauffmann-Lacroix C, Ferrie JC, et al. Paranasal sinus fungus ball and surgery: a review of 175 cases. Rhinology 2005; 43:34.
  8. Pagella F, Matti E, De Bernardi F, et al. Paranasal sinus fungus ball: diagnosis and management. Mycoses 2007; 50:451.
  9. deShazo RD, Chapin K, Swain RE. Fungal sinusitis. N Engl J Med 1997; 337:254.
  10. Drakos PE, Nagler A, Or R, et al. Invasive fungal sinusitis in patients undergoing bone marrow transplantation. Bone Marrow Transplant 1993; 12:203.
  11. Meyer RD, Gaultier CR, Yamashita JT, et al. Fungal sinusitis in patients with AIDS: report of 4 cases and review of the literature. Medicine (Baltimore) 1994; 73:69.
  12. Mylonakis E, Rich J, Skolnik PR, et al. Invasive Aspergillus sinusitis in patients with human immunodeficiency virus infection. Report of 2 cases and review. Medicine (Baltimore) 1997; 76:249.
  13. Colmenero C, Moñux A, Valencia E, Castro A. Successfully treated candida sinusitis in an AIDS patient. J Craniomaxillofac Surg 1990; 18:175.
  14. DelGaudio JM, Clemson LA. An early detection protocol for invasive fungal sinusitis in neutropenic patients successfully reduces extent of disease at presentation and long term morbidity. Laryngoscope 2009; 119:180.
  15. Heier JS, Gardner TA, Hawes MJ, et al. Proptosis as the initial presentation of fungal sinusitis in immunocompetent patients. Ophthalmology 1995; 102:713.
  16. Roithmann R, Shankar L, Hawke M, et al. Diagnostic imaging of fungal sinusitis: eleven new cases and literature review. Rhinology 1995; 33:104.
  17. DelGaudio JM, Swain RE Jr, Kingdom TT, et al. Computed tomographic findings in patients with invasive fungal sinusitis. Arch Otolaryngol Head Neck Surg 2003; 129:236.
  18. Ghadiali MT, Deckard NA, Farooq U, et al. Frozen-section biopsy analysis for acute invasive fungal rhinosinusitis. Otolaryngol Head Neck Surg 2007; 136:714.
  19. Monroe MM, McLean M, Sautter N, et al. Invasive fungal rhinosinusitis: a 15-year experience with 29 patients. Laryngoscope 2013; 123:1583.
  20. Gillespie MB, O'Malley BW. An algorithmic approach to the diagnosis and management of invasive fungal rhinosinusitis in the immunocompromised patient. Otolaryngol Clin North Am 2000; 33:323.
  21. Süslü AE, Oğretmenoğlu O, Süslü N, et al. Acute invasive fungal rhinosinusitis: our experience with 19 patients. Eur Arch Otorhinolaryngol 2009; 266:77.
  22. Herbrecht R, Denning DW, Patterson TF, et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med 2002; 347:408.
  23. Walsh TJ, Anaissie EJ, Denning DW, et al. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2008; 46:327.