Sinus411.org

The web site for people with sinus problems

Fungal Sinusitis

Fungal Sinusitis of two types:  

(1) Allergic Fungal Sinusitis, and

(2) a Mycetoma or Fungus ball in the sinuses.

Surgery of the sinuses is also performed for patients with fungal sinusitis.   There has been a lot of attention in the popular press around the topic of fungal sinusitis, and suffice it to say that there is a lot we know about fungal sinusitis and a lot we do not yet know about what fungus does or doesn’t do in the sinuses.   Some doctors who do research in this field think the vast majority of patients with chronic sinusitis have a fungal infection.    You may have read about their research and theories in the newspaper or a magazine.   Some doctors agree, but many others feel that it’s a minority of patients (not the vast majority) who have fungal infections.   However, it is clear that there are at least 4 different types of fungal sinusitis.   We’ll go into each of these in some detail.   We’ll try to sort out fact from theory, and in some cases fact from fiction, in order to put some order around this information.  But for now, we just want to say that sinus surgery is recommended for the majority of patients who are determined to have fungal sinusitis.  We’ll talk about why later .  

What are the most common types of fungal infection of the sinuses?

Fungal infections occur or commonly in some areas of the United States and world more than they do in other areas of the United States are world.  Specifically, and some of the warmer climates, fungal infections are more common.

There are two common types of fungal infections of the sinuses.  One is called “allergic fungal sinusitis”, and the other is called “fungus ball” or a mycetoma of the sinuses.   They are very different in how they affect patients, how they look on exam, what they look like on CT, and how they are treated, so its very important to distinguish between these two types of fungal sinusitis.  

When is a fungal infection suspected?

Usually, a doctor starts to think about a fungal infection of the sinuses under certain circumstances.  These circumstances are: 

1. A patient with unilateral sinus disease, that is sinus disease all on the left or all on the right side.  Note:  Not all patients with unilateral disease have  fungal sinusitis, but its much more common for unilateral disease to be fungal than for a patient with bilateral disease to have a fungal problem. 
2. A patient with a CT scan that shows the sinuses as having areas of tissue that look like fungal material  (the radiologists and others call them areas of “high density” because they look like they are partially calcified)

Two other (rare) types of fungal infections

To be thorough, there are two other types of rare sinus infections:  Acute invasive fungal sinusitis, and chronic invasive fungal sinusitis.  They are very unusual, so if you want to read on these, please refer to the section on acute invasive fungal sinusitis or chronic invasive fungal sinusitis

Allergic fungal sinusitis

Allergic fungal sinusitis occurs when a small but a fungus gets into the sinus, grows within the sinus, and is not adequately cleaned out by the defenses in the nose and sinuses (specifically by the small hair cells were cilia that sweep the sinuses clean).  In this disease, the fungus stimulates an intense allergic response by the body.  The allergic response causes swelling of the tissues and the growth of polyps or it unfortunately, the polyps grow and, unfortunately, these polyps trap the fungus in the nose and sinuses.  It's a bit of a vicious cycle.  The fungus stimulates the polyps, and the polyps prevent the fungus from leaving the sinuses.  Eventually, the polyps and the fungal debris become so large that they expand, push, in a road into the orbit (eyesocket), into the brain, or elsewhere.  This typically causes symptoms around the eye or brain as well as sometimes causing headaches.  The polyps will usually obstruct the nose when they become large enough and the patient will complain of nasal blockage as well as a decreased sense of smell.

These patients will present with a typical symptoms of chronic sinusitis, but perhaps have less pain than some patients.  Evaluation of these patients ( like most patients with sinusitis) will involve obtaining a CT scan of the sinuses.  Fungus within the sinuses will show up on a CT scan (usually) as an area of increased density, or some brighter spots, and the sinuses.  An experienced radiologist or ENT surgeon will often be looking for these areas of fungus, but sometimes the findings are settled on a CT scan.  However, the expansion and erosion that occur with allergic fungal sinusitis is not subtle if the disease had or has reached a moderate stage and the diagnosis, once considered, is usually easily made.

Treatment of allergic fungal sinusitis requires both medical and surgical intervention.  Prior to the surgery, if fungus is recognized or suspected, a short burst of oral steroid pills may shrink the polyps and allow for the patient to breathe more easily.  Shrinking the polyps also helps make the surgery easier and helps the surgeon eliminate all the small pockets of fungus.

Surgery for allergic fungal sinusitis usually requires complete cleaning of the nose and sinuses.  All the pols must be removed.  All the nooks and crannies in the nose and sinuses that might be harboring bits of fungus must be opened and cleaned out.  Typically the surgeon will your gate the sinuses as well.  It's very important that all the areas containing fungus are adequately examined and cleaned of the fungal debris.  Sometimes this is difficult to perform surgically and it is not unusual to required two or more surgeries to remove this debris.  Like other surgeries, the experience of the surgeon is an important factor.  A surgeon that is treated many cases of allergic fungal sinusitis and has extensive endoscopic sinus surgery experience is more likely to be successful treating this disease and may be able to treat this disease with less surgeries than a surgeon with less experience.

After surgery, it is important that the patients irrigate their nose with salt water to help remove any small bits of microscopic disease.  It is also important that the patient be on oral steroids to prevent the allergic response to any microscopic bits of fungus that remain.  The steroids prevent the polyps from recurring, from trapping the fungus, and from allowing the allergic fungal disease to take root again.  The oral steroids are gradually tapered over a period of many weeks to months, as the surgeon that evaluates the sinuses and is assured that the areas are healing well, with no signs of polyp recurrence.  Unfortunately, oral steroids taken for weeks to months may have side effects.  These need to be discussed with the treating doctor, and once primary care physician should also be aware that one is taking oral steroids for an extended length of time.

Mycetoma or fungus ball the sinuses

A mycetoma or a fungus ball of the sinuses is also small bits of fungus that gets trapped in the nose or sinuses and grows and may cause pressure symptoms, obstructive symptoms, or nasal drainage.  These can be rather low grade symptoms that sometimes.  However, the ball of fungus will eventually become infected with bacteria, and symptoms of sinus infection will become more noticeable with worsening yellow-green nasal discharge, nasal obstruction, facial pain or pressure, and throat or chest symptoms.  Usually, antibiotics will temporarily improve the symptoms from the bacterial infection.  However, the acrobatic cannot penetrate into the fungal mass.  The bacteria will hide in the fungal ball.  When the antibiotic is stopped, the bacterial will usually grow quickly, .  and cause the return of similar symptoms and complaints.  In short, the fungus acts as a foreign body, much like a splinter buried in tissue, it will prevent any bacteria and bacterial infection from being successfully treated.

Treatment of a mycetoma will require that the fungus ball be removed in the sinuses.  After a fungus ball reaches a few millimeters in size, it is basically impossible for the matted fungal material to escape through the small sinus opening.  Therefore, surgery is necessary to remove the fungus, make a sinus openings larger, and wash out any microscopic disease.  Removal of all the fungus is essential, and a surgeon with plenty of endoscopic sinus surgery experience is more likely to have the tools and experience to successfully remove all bits of fungus.  After surgery, saline irrigations are also helpful to remove any small bits of microscopic disease before they can take hold again.  Revision sinus surgery sometimes necessary.