Aspergillus disease can occur in the sinuses, leading to Aspergillus sinusitis. As with the lungs, Aspergillus can cause three diseases here — allergic sinusitis, chronic/recurrent disease or invasive aspergillosis.
Allergic Fungal Rhinosinusitis
Allergic disease is associated with long standing symptoms of a runny, blocked-up nose, and may lead to nasal polyps. Surgical drainage (including removal of polyps); careful attention to treatment of bacterial infection; local steroids; and/or short courses of oral steroids and antifungals applied locally are the approaches to therapy. Aggressive medical management can result in long term remission, but many patients have relapses months or years after surgical clearance.
Saprophytic Sinusitis, Fungal Ball and Chronic Granulomatous Fungal Rhinosinusitis
Saprophytic Sinusitis occurs when Aspergillus fungus grows on top of mucus inside the nose, absorbing the mucous as a form of nutrition. The fungus is effectively “living” off the mucus in the nose. Treatment involves removal of mucous crusts and fungal growth; however, this can be prone to reoccurrence.
A sinus fungal ball caused by Aspergillus develops in a similar way to an aspergilloma. In those with normal immune systems, stuffiness of the nose, chronic headache or discomfort in the face is common. Drainage of the sinus, by surgery, usually cures the problem, unless the Aspergillus has entered the sinuses deep inside the skull. Then antifungal drugs and surgery together is usually successful.
Chronic Granulomatous Fungal Rhinosinusitis patients usually come to clinical attention with nasal obstruction, enlarging mass in the cheek, orbit, nose, maxillae, and paranasal sinuses. The disease has a gradual onset and takes a chronic course, usually over many months, and sometimes years. The patients are typically immunocompetent. CT imaging reveals a soft tissue mass in one or more paranasal sinuses, usually with extension to orbit or brain. The disease is often initially mistaken for malignancy based on nasal endoscopy and CT imaging, as it has a mass-like appearance. Diagnosis is made on histopathology of the biopsy taken or mass removed during surgery. Antifungal therapy is also given after surgical removal. Timely management is effective. Recurrence is rare after prolonged antifungal therapy, which should be for a minimum of six months, if possible.
Invasive Fungal Sinusitis
When patients have damaged immune systems — if, for example they have had leukaemia or a bone marrow transplant — Aspergillus sinusitis is more serious. In these cases, the sinusitis is a form of invasive aspergillosis. The symptoms include fever, facial pain, nasal discharge and headaches. The diagnosis is made by identifying the fungus in fluid or tissue from the sinuses and with scans. Surgery is performed in most cases, as it is often helpful in eradicating the fungus, but also important to find out exactly what is wrong. Treatment with powerful antifungal medicines is essential. Choices of treatment include amphotericin B, caspofungin, voriconazole or itraconazole. Response may be better to amphotericin B than voriconazole or itraconazole; the role of caspofungin is uncertain, as there is little experience.