Other forms of aspergillosis: Chronic Aspergillus Sinusitis

(Chronic invasive and granulomatous forms)

Chronic sinus problems are very common, but in a small number of people they are caused by fungal infection, especially Aspergillus. This type of infection is different from the usual bacterial sinusitis and needs different treatment.

What is chronic Aspergillus sinusitis?

• Chronic rhinosinusitis (CRS) is long-term inflammation of the sinuses (lasting more than 12 weeks).

• In about 6–12% of CRS cases, fungi are the cause — with Aspergillus being the most common.

• There are two important invasive forms that are rare but serious:

  • Chronic invasive Aspergillus sinusitis – the fungus grows slowly into the lining of the sinuses and nearby tissues.

  • Chronic granulomatous Aspergillus sinusitis – the immune system forms a hard granuloma (lump of immune cells and fungus), usually caused by Aspergillus flavus.

These conditions progress slowly but can cause long-term damage if not treated.

Who gets it?

• Chronic invasive Aspergillus sinusitis is more common in Western countries and Japan.

• Granulomatous sinusitis is more often seen in parts of Africa, South Asia (India, Pakistan), the Middle East, and occasionally the southern United States.

• People at risk include:

  • Those with diabetes, on long-term steroids, or with HIV infection.

  • Sometimes people with no obvious immune problems can still develop it.

• Aspergillus fumigatus usually causes chronic invasive sinusitis.

• Aspergillus flavus is the main cause of granulomatous sinusitis.

Symptoms

Because these forms progress slowly, symptoms are often missed or mistaken for “ordinary sinus problems.” They may include:

• Blocked or congested nose that doesn’t improve with usual treatments

• Facial pain or pressure, especially around the eyes, cheeks, or forehead

• Headaches

• Nasal discharge, sometimes blood-stained

• Bleeding from the nose (epistaxis)

• Facial swelling or numbness

• Bulging eye (proptosis) or reduced vision if the infection spreads to the orbit

• Rarely: brain involvement (abscess, meningitis, stroke-like symptoms)

Granulomatous sinusitis often causes a slowly enlarging mass in the nose, cheek, or orbit, and may be mistaken for a tumour.

How is it diagnosed?

• Scans (CT or MRI): show a mass in the sinuses, sometimes with bone damage. MRI is useful if the eye or brain are involved.

• Endoscopy and biopsy: tissue samples are taken from the sinus lining.

• Laboratory tests:

  • Special stains and fungal culture help identify Aspergillus.

  • Blood tests (Aspergillus IgG antibodies) can support the diagnosis.

• Diagnosis can be delayed because the condition is uncommon and mimics other sinus problems.

Treatment

Prompt treatment is essential to prevent serious complications. Management usually involves:

1. Surgery

   • To remove infected tissue and improve sinus drainage.

   • Surgery also allows biopsy to confirm diagnosis.

2. Antifungal medication

   • Long-term antifungal tablets (usually itraconazole or voriconazole).

   • Sometimes intravenous antifungals (e.g. amphotericin B or posaconazole) are used in severe cases.

   • Treatment usually lasts at least 6 months, often longer (sometimes up to a year).

3. Managing risk factors

   • Good control of diabetes.

   • Reducing or stopping steroid medicines if possible.

Outlook (prognosis)

• With early diagnosis and combined treatment (surgery + antifungals), many patients do well.

• Granulomatous sinusitis tends to relapse more often but generally has a better long-term outlook than invasive sinusitis.

• Regular follow-up is essential because recurrence is common.

  • Follow-up usually includes scans every few months and nasal endoscopy to check for regrowth.

  • Ongoing monitoring may be needed for up to 5 years.

Key points for patients

• Chronic Aspergillus sinusitis is rare, but important to recognise because it needs different treatment than ordinary sinus infections.

• Symptoms can mimic chronic sinusitis or even cancer, so biopsy and specialist review are essential.

• Surgery plus antifungal medication is the main treatment.

• Long-term follow-up is needed to monitor for relapse.

• If you have risk factors like diabetes or steroid use, controlling these is important.

✅ Summary:
Chronic invasive and granulomatous Aspergillus sinusitis are rare but serious fungal infections of the sinuses. They progress slowly, can cause damage to the eyes or brain if untreated, and are sometimes mistaken for tumours. With specialist care, surgery, antifungal therapy, and long-term follow-up, most patients can achieve good control of the disease.