Therapy

The effective management of fungal rhinosinusitis requires early diagnosis, its histological classification, surgery and where appropriate chemotherapy. However, systematic algorithm for management of fungal rhinosinusitis is still lacking due to ambiguity in categorization and absence of double blind study to treat such condition. Consensus is that surgery is the initial treatment and the objectives are debridement, wide aeration of infected sinus and providing specimen for histological and microbiological study. After confirmation of diagnosis, the planning of definitive surgery is required. In non-invasive type (fungal ball), surgery may be all that is required.

In fulminant type, the principal of management includes aggressive surgery, minimize immunosuppression or reversal of predisposing factors, and high-dose of conventional amphotericin B or its lipid preparation. However, the role of surgery is uncertain as the patients are usually neutropenic and thrombocytopenic (1, 2).

In chronic invasive or granulomatous invasive type, the issue of adjuvant medical therapy is still uncertain. However, majority of workers feel that medical therapy in conjugation with surgery in invasive disease prevents recurrence and further extension of the disease (1, 3, 4, 2). Though several drugs including amphotericin B, itraconazole, terbinafin, 5-fluorocytosine had been used, no consensus exists about the dose and duration of therapy. Newer drugs like voriconazole, posaconazole, echinocandins are still to be evaluated in such conditions. Intra operative sinus irrigation or repeated packing with amphotericin B ribbon gauze has also been reported (5, 2).

In AFRS, Systemic or nasal corticosteroids, antihistaminics, relevant allergen immunotherapy based on complete inhalant skin testing, antileukotrienes have been proposed (6). These therapies possibly reduce rhinosinusitis activity and forestall the need of recurrent sinus surgery, but further study is required to refine the understanding of management strategies.

References

1. deShazo RD, Chapin K, Swain RE. Fungal sinusitis. New Eng J Med 1997; 337: 254-9.
2. Chakrabarti A, Sharma SC. Paranasal sinus mycoses. Indian Chest Dis Allied Sci 2000; 42: 293-304.
3. Veress B, Malik OA, el-Tayeb AA, el-Daoud S, Mahgoub ES, el Hassan AM. Further observations on primary paranasal Aspergillus granuloma in the Sudan: a morphological study of 46 cases. Am J Trop Med Hyg 1973; 2: 765-72.
4. Washburn RG, Kennedy DW, Begley MG, Henderson DK, Bennett JE. Chronic fungal sinusitis in apparently normal hosts. Medicine 1988; 67: 231-47.
5. Robb PJ. Aspergillosis of the paranasal sinuses: a case report and historical perspective. J Laryngol Otol 1986; 100: 1071-7.
6. Schubert MS. Allergic fungal sinusitis: pathogenesis and management strategies. Drugs 2004; 64: 363-74.