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Fungal rhinosinusitis: fungal ball, allergic and invasive
The first question in fungal rhinosinusitis is whether the fungus invades tissue: non-invasive forms (fungal ball, allergic fungal rhinosinusitis) are treated by surgery alone or surgery and steroids, whereas acute invasive disease in an immunocompromised patient is an emergency of debridement, antifungal therapy and reversal of immunosuppression.
Why it matters in the exam
The exam shows two very different patients. The first is a healthy person with one "full" maxillary sinus on CT containing calcifications — a fungal ball, treated by endoscopic removal without antifungal drugs. The second is a young atopic patient with polyps, thick allergic mucin and a CT with heterogeneous density and expansion of the sinuses — allergic fungal rhinosinusitis (AFRS), a type I hypersensitivity reaction to fungus, treated with surgery and steroids, sometimes with a biologic.
The dangerous form is acute invasive fungal rhinosinusitis: a patient with diabetic ketoacidosis, neutropenia, a transplant or steroid therapy, with fever, facial pain or swelling, reduced sensation and pale or black necrotic nasal mucosa on endoscopy. The organisms are Mucorales (Rhizopus, Mucor) or Aspergillus. Biopsy with rapid staining confirms vascular invasion. Treatment: urgent surgical debridement to bleeding tissue, liposomal amphotericin B (for mucormycosis), and correction of the cause — treating the acidosis, reducing steroids or restoring neutrophils.
The first sign of invasion is often pale, insensate mucosa, before black tissue appears. Spread to the orbit, cavernous sinus and brain greatly raises mortality. Chronic invasive forms (including the granulomatous form) progress over weeks to months, even in immunocompetent people, and are treated with surgery and prolonged antifungal therapy.
Key points
- The key question: is there tissue invasion.
- Fungal ball: removal only.
- AFRS: surgery and steroids.
- Acute invasive: debridement, amphotericin B, correct the cause.
- A diabetic in ketoacidosis with facial pain — mucormycosis until proven otherwise.
Summary table
| Form | Who and what | Treatment |
|---|---|---|
| Fungal ball | Healthy, one maxillary sinus, calcifications on CT | Endoscopic removal only |
| AFRS (allergic) | Atopic, polyps, allergic mucin, sinus expansion | Surgery and steroids |
| Acute invasive | Diabetic ketoacidosis or neutropenia, black or pale mucosa | Urgent debridement and liposomal amphotericin B |
| Chronic invasive | Course of months, sometimes immunocompetent | Surgery and prolonged antifungal therapy |
| Granulomatous invasive | Mass in the cheek or orbit | Surgery and voriconazole |
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Sources
- EPOS 2020: European Position Paper on Rhinosinusitis and Nasal Polyps, 2020 — Fungal rhinosinusitis
- ECMM/MSG-ERC Global guideline for the diagnosis and management of mucormycosis, 2019 — Surgical and antifungal treatment
- Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Fungal rhinosinusitis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.