Fungal Sinusitis Treatment in Delhi, India

Some symptoms of fungal sinusitis are:

• Decreased sense of smell or a continuous bad smell in the nose
• Fever
• Sinus headache
• Nasal congestion and runny nose
• Inflammation (swelling) in the nose and sinuses
• Pain, tenderness, and pressure in the area of the sinus. 
• Pain touching the cheeks or forehead.

People with weakened immunity carry an increased risk of developing severe symptoms such as:

• Behavioural changes and neurological problems.
• Changes in skin colour to very pale or black
• Facial numbness
• Proptosis - protruding of the eyeballs or sticking out from the eye sockets
• Severe swelling in the cheeks or around the eyes
• Changes in vision and blindness

Stages and Types of Fungal Sinusitis

Fungal sinusitis can be classified based on its nature -

1. Non-invasive fungal sinusitis - More common and involves only the nose and sinus
2. Invasive fungal sinusitis - Tends to spread and involves surrounding structures such as the eyes and brain

Non-invasive fungal sinusitis can be further classified as:

1. Allergic fungal rhinosinusitis: The most common type of fungal sinus infection, allergic fungal rhinosinusitis, results from an allergic reaction to fungi within the nose. If untreated, the sinuses fill with thick mucus, leading to the formation of nasal polyps. People with pre-existing conditions such as allergic rhinitis or asthma are prone to developing allergic fungal rhinosinusitis. 
2. Fungal ball (mycetoma):  A fungal ball or clump forms in the sinuses due to fungi build-up that can proliferate and block the sinuses. Surgery is required to remove fungal balls and clear the sinuses.
3. Saprophytic fungal sinusitis: Fungus grows on mucus crusts inside the nose instead of affecting the nose tissue.

Untreated, invasive sinus infections can destroy the nose tissue and spread to the skull and brain. Such conditions are life-threatening. Invasive fungal sinusitis has the following types:

1. Acute fulminant invasive rhinosinusitis: This is a life-threatening condition commonly affecting people with a compromised immune system. Weak immunity is usually due to cancer, chemotherapy, or an organ transplant. The fungi destroy blood vessels within the nose, which leads to tissue necrosis. The infection then spreads to the eyes and brain, leading to vision loss and death. This condition is also known as mucormycosis.
2. Chronic invasive rhinosinusitis: Chronic invasive rhinosinusitis commonly affects people with diabetes. It is similar to mucormycosis but spreads slowly.
3. Granulomatous invasive fungal sinusitis (GIFS): This rare fungal sinusitis occurs when the body launches an immune response to fungi. The person's immune system attacks the nose lining and destroys the nasal tissue.

To diagnose a patient with fungal sinusitis, a doctor first takes a thorough medical history and assesses the symptoms. Then, the doctor may advise some tests to confirm the diagnosis.

• Functional endoscopy of the sinus - a sample is taken from the infected area for lab testing during this procedure. This is the primary method to diagnose patients with fungal rhinosinusitis.
• Polymerase Chain Reaction (PCR) is the most sensitive test with a high Negative Predictive Value (NPV). This makes it ideal for ruling out the possibility of this disease. 
• Frozen Sectioning - A technology used to diagnose invasive fungal sinusitis is frozen sectioning. Debridement tissue from infected sinuses is frozen at -28 degrees Celsius, then sectioned into fragments, and stained for assessment under a microscope. This is a rapid diagnostic test. In addition, there is a mortality benefit for this procedure due to early detection compared to other methods.
• Touch preparation (TP) is an alternative method of diagnosing invasive sinusitis and yields a comparatively rapid and accurate diagnosis. 
• Computed tomography (CT) - A CT scan of the head helps visualise the thickened walls of the sinus and opacifications, bony erosions or ring-enhancing lesions created by the fungal growth.

The treatment of fungal sinusitis varies. Patients with a healthy immune system do not require any treatment for some types of fungal sinus infections. However, invasive fungal sinus infections require immediate treatment or can be fatal. Treatments include:

• Antifungal medications: Medicine helps treat some infections and surgery to remove the infected tissues.
• Corticosteroid medications: Doctors prescribe corticosteroids to reduce inflammation and relieve pressure in the sinus.
• Nasal wash: To treat saprophytic fungal sinusitis, doctors remove mucus crusts and cleanse the sinuses using a saline solution.
• Surgery: Depending on the type of infection, the doctor may advise traditional or minimally invasive endoscopic surgery. An optical probe with a camera is inserted into the nose. Tiny tools are used to remove the fungus, fungal ball, and damaged tissue.

Some complications that may occur due to fungal sinusitis are:

• Cavernous sinus (both eyes are affected) or orbital apex aspergillosis is a rare but life-threatening complication of invasive fungal rhinosinusitis.
• Headaches
• Acute unilateral visual loss
• Pain in the eye

Despite the recent progress in research and analysis of fungal sinusitis, the disease is not well understood and remains challenging to diagnose and treat.

Some forms of fungal sinusitis are more common than others. Risk factors associated with fungal sinusitis are:

• Sex- Women are more likely to develop fungal balls than men.
• Allergic fungal sinusitis commonly occurs in warm, humid climates
• People with weak immunity, like those who take excessive antibiotics, people on immunosuppressant drugs, and medically compromised individuals
• People who are HIV positive
• Have cancer, including leukaemia or lymphoma, or are receiving chemotherapy treatments.
• Have severe or uncontrolled diabetes.
• Take drugs to suppress the immune system (after an organ transplant)

Reviewed by Dr. Vivek Nangia, Principal Director & Head, Pulmonology on 06-Dec-2022.