Sinusitis in Patients with ABPA

When to suspect it, when to investigate, and when to refer

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Why this matters

Patients with allergic bronchopulmonary aspergillosis (ABPA) are usually managed as having a lung disease. Diagnosis, monitoring, and treatment focus appropriately on the chest, immunology, and asthma control.

However, ABPA occurs within a single continuous airway, extending from the nose and sinuses to the lungs. Disease in the upper airway can coexist with, exacerbate, or complicate lower airway inflammation — yet sinus disease is not routinely assessed in ABPA care pathways.

This article outlines:

• What is known about sinus disease in this context

• Which symptoms should raise suspicion

• When investigation or ENT referral should be considered

• What GPs and non-specialists can reasonably do

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The united airway: a brief reminder

The upper and lower airways share:

• Type 2 (eosinophilic) inflammation

• Immunoglobulin E–mediated immune responses

• Common triggers, including allergens and fungi

Chronic rhinosinusitis is common in asthma and severe asthma, and treatment of sinus disease can improve lower airway outcomes in some patients.
ABPA sits within this same inflammatory spectrum, even though its management is lung-centred.

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Sinus disease in ABPA: what is (and isn’t) known

What we know

• Chronic rhinosinusitis is common in patients with asthma and severe asthma

• Sinus disease may be symptomatic or relatively silent

• ABPA guidelines do not mandate routine ENT review or sinus imaging

• ENT involvement, therefore, varies widely between centres

What we do not know

• Whether routine ENT assessment improves ABPA outcomes

• Which ABPA patients benefit most from sinus intervention

• The optimal timing for ENT referral in ABPA

As a result, clinical judgement remains central.

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Symptoms that should prompt consideration of sinus disease

Sinusitis in ABPA patients does not always present with classic “blocked nose and facial pain”.
Key symptoms include:

Common but often overlooked

• Persistent post-nasal drip

• Foul, bitter, metallic, or “infected” taste in the mouth

• Throat clearing, chronic cough

• Thick or sticky mucus sensation

• Symptoms are worse on waking or lying flat

More typical sinonasal features

• Nasal blockage or congestion

• Facial pressure or fullness

• Reduced or altered sense of smell

• Nasal crusting or discharge

Contextual clues

• Poor durability of response to steroids or antifungals

• Recurrent “flares” without clear chest triggers

• Coexisting severe asthma or nasal polyps

• Symptoms are worse in damp or mould-affected housing

A persistent foul taste in the mouth is a recognised symptom of chronic sinus disease, usually due to post-nasal drainage of inflamed secretions.

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Damp homes and sinus disease

Living in damp or mould-affected environments is associated with:

• Higher rates of chronic rhinosinusitis

• Upper airway irritation and inflammation

• Allergic sensitisation to fungal spores

In most cases, this results in inflammatory or allergic sinusitis, not invasive fungal infection.
Fungal involvement may act as an immune trigger, even when not labelled as “fungal sinusitis”.

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Fungal sinusitis: rare vs under-recognised

It is important to distinguish between entities:

Allergic fungal rhinosinusitis overlaps biologically with ABPA:

• IgE-mediated

• Eosinophilic inflammation

• Thick allergic mucin

It is not routinely sought, so it may be under-diagnosed in at-risk groups.

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What GPs and non-specialists can reasonably do

1. Take upper airway symptoms seriously

Especially in ABPA or severe asthma patients with:

• Persistent post-nasal symptoms

• Foul taste

• Recurrent unexplained deterioration

2. Examine the nose and throat

• Look for polyps, discharge, and crusting

• Note mouth breathing or altered voice quality

• Check dentition (to exclude dental causes)

3. Consider imaging when symptoms persist

• CT sinuses (not plain X-ray) is the imaging of choice

• Particularly appropriate if symptoms last >8–12 weeks or recur

4. Refer to ENT when:

• Symptoms are persistent or progressive

• CT shows significant sinus disease

• There is a poor response to standard medical therapy

• There is diagnostic uncertainty

Referral does not imply surgery — ENT input may be diagnostic or medical.

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What this article is not saying

• It does not suggest that all ABPA patients need an ENT referral

• It does not claim that sinus treatment improves ABPA outcomes

• It does not override existing guidelines

It does suggest that earlier consideration of the upper airway is reasonable in selected patients.

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Key take-home points for clinicians

• The airway functions as a single inflammatory system

• Sinus disease may be subtle, under-reported, or atypical

• A foul taste in the mouth is a meaningful symptom

• Damp or mould exposure increases sinus disease risk

• ENT referral is appropriate when symptoms persist or recur

• Evidence gaps remain — but clinical vigilance is justified

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In summary

ABPA is managed as a lung disease, but patients live with a whole airway.
Recognising when sinus disease may be contributing can help explain persistent symptoms and guide appropriate referral — without over-investigation or over-treatment.

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