Aspergillus Sinusitis for Expert Patients and non-Specialist Clinicians

Expert Information for Patients, GPs, and Specialist Nurses

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🔎 What Is Aspergillus Sinusitis?

Aspergillus sinusitis refers to fungal involvement of the paranasal sinuses by Aspergillus species, especially A. fumigatus. It spans a spectrum from benign colonisation to destructive invasive disease, depending on the host’s immune status.

There are four main clinical forms, with distinct presentations and treatment approaches.

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🧬 Main Forms

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👥 Who Is at Risk?

Depends on form:

🟩 AFRS:

• Asthma, eczema, allergic rhinitis

• Nasal polyps

• Fungal IgE sensitisation (esp. Aspergillus)

🟨 Fungal Ball:

• Older adults

• Dental work (esp. upper molars with root involvement)

• Chronic sinus blockage or prior surgery

🟧 Chronic Invasive:

• Long-term corticosteroid or immunosuppressive use

• Poorly controlled diabetes

🟥 Acute Invasive:

• Haematological malignancies

• Bone marrow/stem cell transplant

• Neutropenia or severe COVID-19

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⚠️ Clinical Features

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🧪 Diagnosis

Initial Evaluation:

• Nasal endoscopy: mucosal thickening, polyps, or black necrosis

• CT scan: sinus opacification, bone erosion, hyperdense lesions

• MRI: assesses orbital or intracranial extension in invasive cases

Microbiology & Histopathology:

• Direct microscopy or fungal stain (e.g. GMS)

• Culture for Aspergillus spp.

• Aspergillus-specific IgE/IgG in AFRS

• Tissue biopsy is essential in invasive disease

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💊 Treatment

🟩 AFRS:

• Functional endoscopic sinus surgery (FESS) to clear sinuses

• Oral and topical corticosteroids

• Antifungals (controversial; may reduce recurrence)

• Allergen immunotherapy in selected cases

🟨 Fungal Ball:

• Surgical removal only (FESS)

• No systemic antifungal needed unless complications arise

🟧 Chronic Invasive:

• Surgical debridement

• Long-term oral antifungals (e.g. voriconazole, posaconazole)

• Monitor drug levels and imaging

🟥 Acute Invasive:

• Urgent surgical debridement

• High-dose IV antifungals (voriconazole or liposomal amphotericin B)

• Reversal of immunosuppression

• High mortality if delayed — requires ICU and ID team coordination

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🧾 Monitoring

• Repeat imaging for resolution (especially invasive forms)

• Symptom scores for AFRS and post-FESS recovery

• Antifungal levels and LFTs if systemic therapy used

• Endoscopic surveillance in high-risk or relapsing patients

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📚 More Information

• Specialist input: ENT referral is essential for diagnosis and surgical treatment

• Multidisciplinary management is often needed:

  • ENT, microbiology, infectious diseases, immunology

• Resources: aspergillosis.org, Fungal rhinosinusitis: Education; NHS sinusitis

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