Fungal sinusitis - causes, symptoms, and treatment

Dr. K. R. Meghanadh

What is Sinus?

Sinuses are cavities in the head. There are around 40 sinuses in unique shapes and sizes. Air keeps circulating in these sinuses. Unwanted external substances like bacteria, viruses, fungi, and dust can settle in these sinuses. Sinuses have a mechanism to secrete fluids and flush these unwanted particles into the throat via the nose.

How is Sinusitis Caused?

Before learning about fungal sinusitis, let’s understand how sinusitis is caused. Sinusitis mostly happens when there is a stagnation of fluids in the sinuses.

Whenever fluid stagnation occurs in the sinus, bacteria will start growing in it, causing infection in sinus walls, known as sinusitis. It is one way of resulting in sinusitis.

The other way is that a virulent bacteria (potent bacteria) enters the nose and causes sinusitis without stagnated secretions. Usually, it is rhinosinusitis, where the infection is in the nose and the sinuses, causing inflammation of the sinus and nasal walls. This inflammation can lead to stagnation, starting a vicious cycle.

A person can have sinusitis due to 3 underlying causes.

1. Allergy

2. Anatomical anomalies in sinus drainage pathways

3. Low immunity

What is a Fungal Sinusitis?

Fungal sinusitis is a sinus infection caused by fungus. Several fungi can attack us, and irrespective of the fungal variant, there are three types of fungal sinusitis.

Fungal sinusitis is the rarer version of sinusitis when compared to bacterial.

Sometimes, both fungal and bacterial sinusitis can coexist. In one sinus, a person can have bacterial and in the other, a fungal infection. A person can have various types of fungal sinusitis simultaneously.

Diagnosing the problem can be challenging because there are so many possible combinations of factors. However, once we figure out the correct diagnosis, we have a better chance of successfully fixing the issue.

Types of Fungal Sinusitis

Fungal sinus infections can be broadly classified into three types based on the behavior of the disease but not on the type of fungi.

1. Non-invasive fungal sinusitis or localized fungal sinusitis

2. Invasive fungal sinusitis

3. Fulminant fungal sinusitis - mucormycosis (black fungus), white fungus

It is interesting to know that a person can have multiple types of fungal sinus infections simultaneously.

Non-Invasive Fungal Sinusitis

Among the three varieties of fungal sinusitis, non-invasive fungal sinusitis stands out as the most prevalent. When someone uses the term fungal sinusitis, they refer to the non-invasive type.

In this type, the fungus remains confined to the sinus cavities, refraining from entering the tissues. In non-invasive fungal sinusitis, our body generates killer cells at a rate comparable to the growth of the fungus, effectively combating fungus. This immune response is a barrier, preventing the fungus from entering the bloodstream or surrounding tissues.

There are two types of non-invasive fungal sinusitis.

1. Fungal ball

2. Allergic Fungal Rhinosinusitis (AFRS)

The symptoms of the fungal ball are negligible, whereas, in allergic rhinosinusitis, the symptoms are more.

Invasive Fungal Sinusitis

Unlike non-invasive, in invasive, the fungus spreads into the tissues and doesn’t remain confined to the sinus, making it dangerous compared to non-invasive. Invasive is a rare type of fungal infection and occurs only when a person’s immunity is down.

You can click here for more information.

Fulminant Invasive Fungal Sinusitis

Although the fulminant fungal infection is a subtype of invasive sinusitis, when we say invasive, we usually refer to non-fulminant invasive fungal sinusitis. The immunity needs to go super even low to get a fulminant fungal infection. In these infections, the fungus doesn’t just spread through tissues but also through blood vessels making it not just comparatively dangerous to non-invasive and invasive, but also life-threatening.

It is important to note that with invasive or non-invasive, people can live for years without treatment. Although treatment is inevitable to cure the disease. However, in fulminant delaying the treatment by a day can worsen the situation to a whole new level. A person can lose eyes, jaw, or even life. The fungus grows so fast that it can double in just a few hours. Without aggressive treatment, death is inevitable, and there is no scope for miracles without the treatment. So, powerful antifungals are given through IV on suspicion before the confirmation of the disease, as doctors cannot risk the patient's life. Once confirmed, they start with debridement surgeries. A minimum of 2 surgeries are required, and the maximum has no limit. The author’s maximum record is over 20 on a single patient.

Fulminant fungal infection can be caused by the below-listed fungi.

1. Mucor

2. Candida

3. Aspergillosis

Mucormycosis, caused by mucor, is the most common type of fulminant fungal infection. It is commonly known as black fungus infection.

COVID-19 is one of the diseases that triggered fulminant fungal sinusitis. They are famously known as post-COVID black fungus and post-COVID white fungus cases (fulminant sinusitis caused by candida or aspergillosis).

Pre-COVID, fulminant fungal sinusitis is even rarer than invasive fungal sinusitis.

Fungal Sinusitis Causes

Fungal sinusitis can be caused due to a long-standing chronic bacterial sinus infection or when a person’s immune system is weak.

Chronic Bacterial Sinusitis turning into Non-Invasive Fungal Sinusitis

Multiple theories have been proposed to explain the causes of fungal sinusitis. However, one of the widely accepted postulated theories is that when fluids stagnate in sinuses, bacteria grow in them. To kill the bacteria, our immune system will produce WBCs. These WBCs creep into the sinus secretions present in the infected sinuses. WBCs successfully kill the bacteria, but they cannot go back into the blood, so they ideally must be drained through the natural drainage process. But, due to the inflammation in the sinuses caused by infection, the drainage has already been blocked, so the fluid containing a lot of dead bacteria and WBCs might find it difficult to escape the sinus. So these fluids will turn into puss and become food for the fungus. Any organism to live requires food and water, making such sinuses an ideal hub for fungi growth. So, the fungus that enters our body will thrive in these sinuses, causing fungal sinusitis. This theory is for the most common type of fungal sinusitis called non-invasive. The other types are rare.

Low Immunity

While other two types, invasive and fulminant invasive, are caused when the immune system takes a hit. A non-invasive fungal sinusitis could turn into invasive when your immunity has gone down, or invasive fungal sinusitis could be a whole new fungal infection.

Fulminant Invasive

Fulminant invasive fungal sinusitis is mostly caused by a fungus called mucor. The other two fungi responsible for fulminant infections are Candida and Aspergillosis. Mucor is a fungus that you can find on rotten fruits and vegetables. The black powdery substance you see on onions is also mucor, which is responsible for causing a fulminant infection called mucormycosis or commonly known as black fungus.

We can find this fungus easily, and we breathe the mucor fungus spores responsible for this infection daily. Our body is far stronger than the fungus, and hence we don’t get this deadly infection. Only when our immune system is very weak we can contract this fungus and this type of infection.

It has been observed that fulminant fungal infections are mostly caused in people with below conditions.

• Organ transplant patients on immune suppressants

• Cancer patients on anti-cancer drugs

• Immune deficiency syndromes Eg: AIDS

• Patients who are on steroids for months

• Uncontrolled diabetic patients

Fungal Sinus Infection Symptoms

Fungal sinus infection symptoms depend on the type of fungal sinusitis. It depends on both the nature of the disease and, in some cases, the type of fungus.

Symptoms of Non-Invasive Fungal Sinusitis

• Runny nose

• Nasal congestion

• Headache

• pain in facial parts

• Phlegm drainage from the nose to the back of the throat necessitates throat-clearing

• Sore feeling in throat

• Frequent bouts of coughing

During the initial stages of non-invasive fungal sinusitis, the symptoms closely resemble those of bacterial or common sinus infections. These symptoms can be subtle or even absent, making it challenging to differentiate non-invasive fungal sinusitis from other sinus conditions. In cases where symptoms are noticeable, they are often attributed to bacterial sinusitis rather than the presence of the fungus within the sinuses.

Symptoms of Invasive Fungal Sinusitis

• Pain and/or inflammation in the eye, nose, teeth, or cheek

• Disturbances in vision, such as double vision or diminishing vision

• Loosening of teeth if the infection extends to the jaw bone

• Loss of sensation in the cheek

• Facial swelling in rare instances when the infection spreads to the skin

• Impact on the specific body part controlled by the affected area of the brain if the infection reaches the brain.

Read the article on invasive fungal sinusitis for more details.

https://www.medyblog.com/post/invasive-fungal-sinusitis-treatment-diagnosis-symptoms

Fulminant Fungal Sinusitis Symptoms

Fulminant fungal sinusitis infection symptoms, irrespective of the type of fungus, are almost the same.

The first symptom is severe facial pain, followed by other symptoms. If a person reaches hospital and receives the treatment immediately, the chances of survival are very high. If you wait for other symptoms, the chances of survival get exponentially low

• Severe nose pain

• Severe tooth pain

• Severe eye pain

• Nose block

• Nasal discharge

• Double vision

• Deterioration of eyesight

• Swelling of the eye, nose, or cheek

• Watering of the eye

• redness of the eye

We see differences in symptoms in later stages only. We get white, grey, and black nasal discharges for Candida, Aspergillosis, and Mucormycosis, respectively. This is a rare symptom and might not occur.

How to Diagnose Fungal Sinusitis

The toughest part of treating fungal sinusitis is diagnosing it.

Just like symptoms, the fungal sinusitis diagnosis also depends on the type of fungal sinus infection.

Non-Invasive Fungal Sinusitis

Identifying non-invasive fungal sinusitis solely based on symptoms can be challenging, as the presented symptoms often mimic allergic reactions or coincide with those of bacterial sinusitis. To diagnose non-invasive fungal sinusitis, doctors will do endoscopy, CT scans, fungal smears, and culture to ensure a more accurate diagnosis. This thorough diagnostic process enables doctors to accurately discern the specific type of fungus causing the sinus infection.

Invasive Fungal Sinusitis Diagnosis

Diagnosing invasive fungal sinusitis poses a complex challenge, requiring a Histopathology examination of a biopsy. This small surgical procedure, performed by an ENT surgeon, involves removing tissue from the body. The challenge lies in pinpointing the most suitable biopsy site for the ENT physician. Tests like nasal endoscopy, MRI, and CT scans aid in determining the location, and the ENT doctor’s expertise is crucial in identifying the affected body part accurately.

Please click here for more details.

Fulminant Sinusitis Diagnosis

The diagnosis of fulminant sinusitis typically involves a nasal endoscopy to visualize nasal and sinus passages. During the nasal endoscopy, a small part of the diseased tissue is carefully scraped or collected. This tissue sample is then sent to a laboratory for detailed testing. The laboratory analysis plays a crucial role in confirming the diagnosis of fulminant sinusitis.

Read here about the diagnosis.

Fungal Sinusitis Treatment

The treatment of fungal sinusitis can involve

1. Surgery

2. Antifungals – oral only or both oral and IV

3. Antiallergic medications

However, the specific goals of surgery and the way antifungal medications are used depend mainly on the type of fungal sinusitis.

Non-Invasive Fungal Sinusitis  Treatment

Since the fungus is within the sinuses, antifungals cannot reach them, making surgery compulsory for non-invasive fungal sinusitis.

Surgical procedures are done to eliminate substantial fungal accumulations and to prevent further fluid buildup, and there will be some rectification in sinus drainage pathways.

If a person has an allergic reaction to fungus, i.e., allergic fungal rhinosinusitis type, then allergy medications are added to treat the symptoms.

Invasive Fungal Sinusitis Treatment

Oral antifungal medications are the primary approach to treating invasive fungal sinusitis. Surgical procedures, such as debridement, are not required. As the fungal is present in the tissues, the medication works effectively.

But, sometimes, a person might have both invasive and non-invasive fungal sinusitis at a given time. Then the surgery is inevitable due to non-invasive fungal sinusitis.

Fulminant Fungal Sinusitis Treatment

Treatment for fulminant fungal sinusitis involves a combination of multiple debridement surgical procedures and multiple IV and oral antifungal medications to combat the fungal infection. The treatment will be aggressive and tailored according to the patient’s condition. The patient will not have much time to live if treatment is not aggressive and not started in the early stages.

Written by

Dr. K. R. Meghanadh

FAQs

Is fungal sinusitis an emergency?

Yes, fungal sinusitis is an emergency if it is a fulminant invasive fungal sinusitis type. It might be an emergency if it is invasive or non-invasive.

Fulminant fungal sinusitis is a rapidly spreading condition, capable of reaching the brain and killing a person within weeks. Its rapid progression results in the doubling of fungal growth within hours. While this is a rare form of fungal sinusitis, it can be seen only in individuals with weakened immunity.

Invasive, which is also rare, is not an emergency due to a slow spread. Although it is life-threatening, it can take years to reach the brain.

Non-invasive can become an emergency only when it affects the eyes and brain.

What kills sinus fungus?

Antifungals kill sinus fungus.

For non-invasive and fulminant forms of the disease, antifungal medication is not the primary form of treatment. However, in cases of invasive fungus, antifungal medication is the primary treatment option.

Non-invasive forms of sinus fungus include fungal ball and allergic fungal rhinosinusitis. Treatment for a fungal ball requires a surgical procedure to drain the fungus along with antifungal medication. For allergic fungal rhinosinusitis, antiallergic medication and antifungals are necessary.

In invasive cases, the fungus is present in the tissue and antifungal medication can reach it easily through the bloodstream. Surgery is not required in these cases, as antifungals alone can effectively treat the disease.

Fulminant fungal sinusitis, such as black fungus or white fungus, rapidly spreads and while strong antifungal medication can kill the fungus, it cannot keep pace with its growth. In these cases, surgery is inevitable. For more information, see our article on mucormycosis treatment.

Does fungal sinusitis require surgery?

Yes, if the fungal sinusitis is non-invasive or fulminant invasive types. For a typical invasive fungal sinusitis, only a small biopsy will be required for diagnostic purposes but not treatment.

Will a CT scan show fungal sinusitis?

CT scans can show fungal contents inside the sinuses and help in diagnosis.

We can see a gray shadow with white color shadows inside the sinuses. You can check out our diagnosis article for more details.

is sinus infection

https://www.medyblog.com/post/sinusitis-diagnosis-ct-scan-nasal-endoscopy

How do you treat fungal sinusitis?

The treatment approach for fungal sinusitis varies depending on its specific type. Fungal sinusitis can be classified into three main types:

1. Non-invasive fungal sinusitis: As the fungus is inside the sinuses and antifungals cannot reach them, surgery is compulsory for non-invasive fungal sinusitis. We have two types of non-invasive fungal sinusitis a. Fungal ball: Doctors will opt for surgical procedures to remove the high amounts of fungus and make corrections in sinus drainage pathways to avoid the stagnation of fluids. b. Allergic fungal rhinosinusitis: In the case of allergic fungal rhinosinusitis, a combination of antiallergic medication and surgical procedures will be recommended. Although most symptoms disappear or subside on the use of anti-allergic medication. Additionally, if the sinuses show a significant fungal presence, doctors might prescribe antifungal medication to supplement the treatment.
   

2. Invasive fungal sinusitis: The treatment for invasive fungal sinusitis revolves around antifungal medication. Doctors will prescribe antifungal drugs to target and eliminate the fungal infection. Doctors should not opt for surgical procedures like debridement in invasive.
   

3. Fulminant fungal sinusitis: treatment for fulminant fungal sinusitis involves a combination of multiple debridement surgical procedures and multiple antifungal medications to combat the fungal infection. The treatment will be aggressive and tailored according to the patient's condition. The patient will not have much time to live if it is not aggressive.