Other forms of Aspergillosis: 🔬 Acute Invasive Aspergillus Sinusitis (AIAFS)

Updated: 17 August 2026

What is acute invasive Aspergillus sinusitis?

Acute invasive Aspergillus sinusitis is a form of acute invasive fungal rhinosinusitis (AIFR) in which Aspergillus grows into the tissues lining the nose and sinuses.

This is fundamentally different from more common forms of fungal sinus disease such as allergic fungal rhinosinusitis (AFRS) or a fungal ball. In those conditions fungal material remains outside healthy tissue. In invasive disease, fungal hyphae penetrate tissue and may invade blood vessels, bone and surrounding structures.

The infection can potentially spread from the sinuses into the orbit around the eye, skull base, blood vessels or brain. For this reason, suspected acute invasive fungal rhinosinusitis is treated as a medical emergency.

Aspergillus is an important cause, but not the only one. Acute invasive fungal rhinosinusitis can also be caused by fungi belonging to the Mucorales, which cause mucormycosis. Identifying the organism is important because treatment may differ.

Who is at risk?

Most people who develop acute invasive fungal rhinosinusitis have an underlying condition that significantly reduces their ability to control fungal growth.

Important risk factors include:

• prolonged or profound neutropenia
• haematological malignancies such as leukaemia
• chemotherapy causing substantial immune suppression
• haematopoietic stem-cell transplantation
• solid-organ transplantation
• high levels of immunosuppressive treatment
• some severe inherited or acquired immune deficiencies
• poorly controlled diabetes, particularly diabetic ketoacidosis

Diabetes is especially strongly associated with invasive fungal rhinosinusitis caused by Mucorales, while profound neutropenia and haematological malignancy are important settings for invasive aspergillosis.

Risk is therefore determined by the whole clinical picture rather than by one diagnosis or medicine alone.

Can it occur in someone with a normal immune system?

Acute invasive fungal rhinosinusitis is very uncommon in people without significant risk factors, but it is better not to describe the risk as absolutely zero.

There are also chronic and granulomatous forms of invasive fungal rhinosinusitis that behave differently and may occur in people without the profound immune suppression typically associated with acute disease.

For most people living with chronic forms of aspergillosis such as ABPA or CPA, the presence of ordinary sinus symptoms does not mean they are developing acute invasive fungal sinusitis.

What symptoms can occur?

Early symptoms can be non-specific and may resemble ordinary sinusitis. This is one reason the patient’s underlying risk factors are so important.

Possible symptoms and signs include:

• nasal congestion or discharge
• facial or sinus pain
• headache
• fever
• facial swelling
• nasal ulceration or abnormal tissue
• reduced facial sensation or numbness

Features suggesting spread beyond the sinuses can include:

• visual disturbance
• double vision
• pain or difficulty moving the eye
• protrusion or swelling of the eye
• severe or rapidly worsening headache
• cranial nerve abnormalities
• confusion or other neurological symptoms

Dark or necrotic nasal tissue is a recognised feature of advanced invasive fungal disease, but its absence does not rule the condition out. Treatment should not wait for dramatic late signs to appear.

Why early diagnosis matters

Acute invasive fungal rhinosinusitis can progress rapidly because fungal growth may invade blood vessels, reducing blood supply to infected tissue and allowing disease to extend into nearby structures.

The orbit and intracranial structures are particularly important because of their close anatomical relationship with the paranasal sinuses.

Prompt recognition, investigation and treatment are therefore central to improving outcome.

How is it diagnosed?

There is no single blood test, scan or symptom that reliably confirms or excludes acute invasive fungal rhinosinusitis.

Diagnosis usually involves several approaches used together.

ENT examination and nasal endoscopy

Urgent examination by an ear, nose and throat (ENT) specialist may identify abnormal mucosa, ulceration, reduced sensation, necrotic tissue or other suspicious changes.

However, early disease may be subtle, particularly in severely immunocompromised patients.

CT scanning

CT is useful for assessing the sinuses and surrounding bone and may identify sinus opacification, tissue infiltration or extension beyond normal sinus boundaries.

Early imaging changes may be relatively non-specific, so a reassuring-looking CT does not necessarily exclude early invasive disease in a very high-risk patient.

MRI

MRI can be particularly useful when there is concern about involvement of the orbit, blood vessels, skull base or intracranial structures.

Biopsy and histopathology

Demonstrating fungal invasion of tissue is central to confirming invasive fungal rhinosinusitis.

Suspicious tissue may therefore be biopsied urgently and examined by histopathology using fungal stains.

This also helps distinguish invasive infection from conditions such as AFRS or fungal ball, where fungal hyphae may be present but remain outside the tissues.

Fungal culture and identification

Samples should also be sent for fungal culture and identification where possible.

Culture can help identify whether Aspergillus, Mucorales or another fungus is involved and may provide information useful for antifungal treatment. However, fungal cultures can sometimes be negative even when histopathology demonstrates invasive disease.

How is it treated?

Acute invasive Aspergillus sinusitis usually requires a combination of:

• urgent endoscopic surgery
• systemic antifungal treatment
• treatment or reversal of the underlying risk factor where possible

Care normally involves a multidisciplinary team including ENT surgeons, infectious diseases or medical mycology specialists, microbiologists, radiologists and the specialists managing the patient’s underlying condition.

Surgery

Surgery aims to remove infected and necrotic tissue, reduce the fungal burden, obtain tissue for diagnosis and restore access to affected areas.

Some patients require more than one operation because the extent of viable and infected tissue can change as treatment progresses.

The 2023 multidisciplinary consensus review of acute invasive fungal rhinosinusitis supports management using a combination of surgery, systemic antifungal treatment and correction of underlying immune suppression where possible.

Antifungal treatment

Systemic antifungal treatment is started urgently when invasive fungal infection is suspected or confirmed.

The choice of treatment depends on several factors, including:

• the suspected or identified fungal species
• previous antifungal treatment
• local and individual antifungal susceptibility information
• kidney and liver function
• other medicines being taken
• the extent and severity of infection

For invasive Aspergillus sinusitis, published IDSA aspergillosis guidance recommends surgery together with systemic mould-active antifungal therapy.

Mucormycosis requires a different therapeutic approach, which is another reason why microbiological and histological identification is important.

Therapeutic drug monitoring

Some mould-active azole antifungal medicines show considerable variation in blood concentrations between patients and may interact with other medicines.

Therapeutic drug monitoring (TDM) may therefore be used where appropriate to help ensure adequate exposure while reducing the risk of toxicity.

Whether TDM is required depends on the antifungal being used and the clinical situation; it is not a universal requirement for every antifungal treatment.

Correcting the underlying risk factor

Antifungal treatment and surgery are only part of management.

Where possible, clinicians may also try to improve the patient’s ability to control the infection. Depending on the individual situation this might involve:

• recovery from neutropenia
• reviewing immunosuppressive treatment
• improving control of diabetes
• correcting diabetic ketoacidosis
• managing the underlying haematological or immune disorder

These decisions can be complex because reducing immune suppression is not always possible or safe.

What is the outlook?

Acute invasive fungal rhinosinusitis remains a serious infection with substantial risk of severe complications and death.

Outcome varies widely according to:

• how early the disease is recognised
• the degree of immune suppression
• duration of neutropenia
• the causative fungus
• whether disease has spread into the orbit, blood vessels or brain
• whether adequate surgical treatment is possible
• response to antifungal treatment
• whether the underlying risk factor can be reversed

For these reasons, a single percentage mortality figure can be misleading. Published series include very different groups of patients and disease severity.

A 2025 review of current evidence in invasive fungal rhinosinusitis emphasises that prognosis depends on multiple clinical factors and that important evidence gaps remain around optimal timing, duration of treatment and surveillance.

What should patients with ABPA or CPA know?

People living with ABPA, chronic pulmonary aspergillosis (CPA) or other long-term Aspergillus-related lung conditions may understandably worry when they read about invasive fungal sinusitis.

These diseases are not the same condition.

Having ABPA or CPA alone does not mean that acute invasive Aspergillus sinusitis is likely to develop. The risk becomes more relevant when additional major factors are present, such as profound neutropenia, haematological malignancy, transplantation or substantial immune suppression.

Ordinary chronic sinus symptoms should still be assessed appropriately, but they should not automatically be interpreted as evidence of invasive fungal infection.

When is urgent assessment needed?

People with major risk factors for invasive fungal infection should seek urgent medical assessment if they develop new or rapidly worsening sinus or facial symptoms, particularly:

• rapidly worsening facial pain or swelling
• new facial numbness
• visual disturbance or double vision
• difficulty moving an eye
• severe or unusual headache
• black, ulcerated or necrotic nasal tissue
• confusion or neurological symptoms

In a severely immunocompromised patient, clinical concern should prompt urgent specialist assessment even when early symptoms appear relatively mild.

Further information

• Fungal Rhinosinusitis – patient overview
• Aspergillus Sinusitis for Expert Patients and non-Specialist Clinicians

References and further reading

1. Roland LT, Humphreys IM, Le CH, et al. Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations. International Forum of Allergy & Rhinology. 2023;13(9):1615–1714. PubMed PMID: 36680469.
2. Ji J, Roland LT. Invasive fungal rhinosinusitis: current evidence and research opportunities. Current Opinion in Otolaryngology & Head and Neck Surgery. 2025;33(1):20–30. PubMed PMID: 39146258.
3. Chen A, Pietris J, Bacchi S, et al. Imaging Features of Invasive Fungal Rhinosinusitis: A Systematic Review. Canadian Association of Radiologists Journal. 2024;75(3):601–608. PubMed PMID: 38344986.
4. Patterson TF, Thompson GR III, Denning DW, et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2016;63(4):e1–e60. IDSA Aspergillosis Guideline.
5. Cornely OA, Alastruey-Izquierdo A, Arenz D, et al. Global guideline for the diagnosis and management of mucormycosis. Lancet Infectious Diseases. 2019;19(12):e405–e421. Full text.