Sinus Secrets: Understanding Fungal Ball and its Recent Surge.

Fungus ball  also known as ‘aspergilloma’, are noninvasive accumulations of dense conglomeration, consisting of fungal mycelia, inflammatory cells, fibrin, mucus, and tissue debris. They typically develop in the paranasal sinus and lung cavities, often as a result of fungal infections in individuals with weakened immune systems.

 These fungus balls typically develop unilaterally, affecting one side, and the most commonly involved sinus is the maxillary sinus.

Etiology:

With the growing use of antibiotics and immunosuppressant drugs, as well as the rise in the number of diseases that weaken the immune system, the incidence of fungus balls, particularly in the maxillary sinus, is increasing.

Indeed, people with weakened immune systems are at a higher risk of developing fungal sinus infections. Severe infections are more commonly observed in individuals who:

• Are HIV positive.
• Have cancer, including leukemia or lymphoma, or are undergoing chemotherapy treatments.
• Have severe or uncontrolled diabetes.
• Take medications to suppress the immune system, such as those prescribed after an organ transplant.

Symptoms:

Fungal sinus infections can manifest with a range of symptoms. These may include a

• Decreased sense of smell or Parosmia -an unpleasant odor in the nose,
• Accompanied by fever and inflammation in the nasal and sinus passages.
• Nasal congestion and a runny nose are common,
• Pain, tenderness, and pressure in the sinus area,
• Discomfort when touching the cheeks or forehead.

 Evaluation and Diagnosis:

When evaluating a suspected fungal sinus infection, we typically conduct a series of investigations to determine the extent and nature of the condition. These investigations commonly include

• ENT (Ear, Nose, and Throat) examination, which involves a thorough assessment of the nasal and sinus passages.
• Nasal endoscopy may be performed to provide a closer look at the affected areas .
• CT scan or MRI (Magnetic Resonance Imaging) to visualize the sinuses and assess the extent of infection and any potential complications.

These diagnostic tools help guide treatment decisions and ensure effective management of fungal sinus infections.

MANAGEMENT

The treatment of fungal sinus infections, particularly aspergillosis, involves various approaches depending on the severity and patient's condition.

Medical Management:

AZOLES- Voriconazole is typically the first-line therapy and may be used in combination with other antifungal agents like caspofungin. Isavuconazole is another  antifungal agent indicated for invasive aspergillosis. In cases of treatment failure, amphotericin, especially in lipid formulations, may be prescribed. Other antifungal options include posaconazole, itraconazole, , and micafungin.

Steroids may also be part of the treatment plan, especially if there is a clear allergic history or if the patient has conditions like asthma or concomitant allergic bronchopulmonary aspergillosis.

 Surgical Management:

-In some instances, Functional Endoscopic Sinus Surgery (FESS) may be necessary. This surgical procedure aims to remove the fungal ball and involves irrigating the sinus to clear the infection and alleviate symptoms.

Treatment approaches are tailored to the individual patient's condition and response to therapy, and it's important to consult with a healthcare provider for a comprehensive assessment and personalized treatment plan.

The purpose of this article is to create awareness among clinicians of all specialties regarding the recent surge, varying clinical presentations and management of fungal rhinosinusitis especially Aspergillomas.