Fungal infections of the sinuses have recently been blamed for causing most cases of chronic
rhinosinusitis. The evidence, however, is still very controversial. Most fungal sinus infections are
benign or noninvasive, except when they occur in individuals who are immunocompromised.
Distinguishing invasive disease from noninvasive disease is important because the treatment and
prognosis are quite different. Noninvasive disease has 2 varieties of presentations, and invasive
disease has 3 varieties of presentations.
Non-invasive fungal sinusitis:
Allergic fungal sinusitis
Allergic rhinitis is prevalent in this group and is considered to be the trigger mechanism behind
allergic fungal sinusitis. Patients are immunocompetent and often have asthma, eosinophilia, and
elevated total fungus-specific immunoglobulin E (IgE) concentrations.
Symptoms include facial pressure, headache, nasal stuffiness, discharge, and cough. The
condition should be suspected in individuals with intractable sinusitis and nasal polyposis.
Some patients may present with proptosis or eye muscle entrapment. These patients usually have
atopy and have had multiple surgeries by the time of diagnosis. CT scanning of the sinuses
reveals opacification with concretions and/or calcifications.
Treatment includes both surgery and medical therapy.
Surgery reveals greenish black or brown material (ie, allergic mucin), which has the consistency
of peanut butter mixed with sand and glue. Allergic mucin and polyps may form a partially
calcified expansile mass that obstructs sinus drainage. Growth of the mass may cause pressureinduced
erosion of bone, rupture of sinus walls, and occasional leakage of the sinus contents into
the orbit or brain.
This condition is usually unilateral and involves the maxillary or sphenoid sinus. Mucopurulent,
cheesy, or claylike material is present at the time of surgery. Patients with sinusitis mycetoma are
Presentation is similar to that of patients with chronic sinusitis. Examination may reveal
polyposis with evidence of sinusitis, mainly on one side. Usually, sinus mycetoma is the result of
incidental fiding on CT scan. Treatment is usually surgical
Invasive fungal sinusitis:
Acute invasive fungal sinusitis
Acute invasive fungal sinusitis results from a rapid spread of fungi through vascular invasion
into the orbit and CNS. It is most common in patients with who are immunocompromised..
Typically, patients with acute invasive sinusitis are severely ill with fever, cough, nasal
discharge, headache, and mental status changes. High index of suspicion is important especially
in patients with HIV or diabetes meelitus.
Signs and symptoms include dark ulcers on the septum, turbinates, or palate. In the late stages,
signs and symptoms of cavernous sinus thrombosis are present.
Emergent surgery is indicated followed by systemic anti-fungal therapy and treatment of the
Chronic invasive fungal sinusitis
Chronic invasive fungal sinusitis is a slowly progressive fungal infection with a low-grade
invasive process and usually occurs in patients with diabetes. Symptoms are usually long-term
and not acute. Orbital symptoms can occur if left untreated.
Patients present with symptoms of long-standing sinusitis. Symptoms are usually not acute, and
fever and mental status changes are absent. Nasal examination findings can be minimal.
Treatment involves surgery and anti-fungal therapy.
Granulomatous invasive fungal sinusitis
This condition has been reported almost exclusively in immunocompetent individuals from
North Africa. Symptoms include those of chronic sinusitis. While nasal examination can be
unimpressive, orbital fidings such as proptosis can occur. Treatment involves surgery and antifungal