Noninvasive Fungal Sinusitis

  • Ashleigh A. Halderman
  • Matthew W. RyanEmail author


The severity of fungal rhinosinusitis ranges from benign fungal balls to life-threatening acute invasive fungal sinusitis. Fortunately, the most commonly encountered forms of fungal rhinosinusitis are on the benign end of the spectrum: fungal balls and allergic fungal rhinosinusitis (AFRS). While fungal balls and AFRS share a common feature— fungus—the pathophysiology, management, and outcomes are considerably different. This chapter reviews these two types of noninvasive fungal rhinosinusitis, with an emphasis on pathophysiology and clinical management.


Fungal ball Mycetoma Allergic fungal rhinosinusitis Allergic mucin Functional endoscopic sinus surgery Immunotherapy 


  1. 1.
    Hora JF. Primary aspergillosis of the paranasal sinuses and associated areas. Laryngoscope. 1965;75:768–73.CrossRefPubMedGoogle Scholar
  2. 2.
    Ferreiro JA, Carlson BA, Cody DT III. Paranasal sinus fungus balls. Head Neck. 1997;19(6):481–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Dufour X, Kauffmann-Lacroix C, Ferrie JC, Goujon JM, Rodier MH, Klossek JM. Paranasal sinus fungus ball: epidemiology, clinical features and diagnosis. A retrospective analysis of 173 cases from a single medical center in France, 1989-2002. Med Mycol. 2006;44(1):61–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Nicolai P, Lombardi D, Tomenzoli D, et al. Fungus ball of the paranasal sinuses: experience in 160 patients treated with endoscopic surgery. Laryngoscope. 2009;119(11):2275–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Klossek JM, Serrano E, Peloquin L, et al. Functional endoscopic sinus surgery and 109 mycetomas of paranasal sinuses. Laryngoscope. 1997;107(1):112–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Jiang RS, Hsu CY. Serum immunoglobulins and IgG subclass levels in sinus mycetoma. Otolaryngol Head Neck Surg. 2004;130(5):563–6.CrossRefPubMedGoogle Scholar
  7. 7.
    Mensi M, Piccioni M, Marsili F, Nicolai P, Sapelli PL, Latronico N. Risk of maxillary fungus ball in patients with endodontic treatment on maxillary teeth: a case-control study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103(3):433–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Nicolai P, Mensi M, Marsili F, et al. Maxillary fungus ball: zinc-oxide endodontic materials as a risk factor. Acta Otorhinolaryngol Ital. 2015;35(2):93–6.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Ponikau JU, Sherris DA, Kern EB, Homburger HA, Frigas E, Gaffey TA, et al. The diagnosis and incidence of allergic fungal sinusitis. May Clin Proceed. 1999;74(9):877–84.CrossRefGoogle Scholar
  10. 10.
    Aribandi M, McCoy VA, Bazan C. Imaging features of invasive and noninvasive fungal sinusitis: a review. Radio Graphics. 2007;27:1283–96.Google Scholar
  11. 11.
    Montone KT, Livolsi VA, Feldman MD, et al. Fungal rhinosinusitis: a retrospective microbiologic and pathologic review of 400 patients at a single university medical center. Int J Otolaryngol. 2012;2012:684835.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Granville L, Chirala M, Cernoch P, Ostrowski M, Truong LD. Fungal sinusitis: histologic spectrum and correlation with culture. Hum Pathol. 2004;35:474–81.CrossRefPubMedGoogle Scholar
  13. 13.
    Ence BK, Gourley DS, Jorgensen NL, Shagets FW, Parsons DS. Allergic fungal sinusitis. Am J Rhinol. 1990;4:169–78.CrossRefGoogle Scholar
  14. 14.
    Marple BF. Allergic fungal rhinosinusitis: current theories and management strategies. Laryngoscope. 2001;111(6):1006–19.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Lu-Myers Y, Deal AM, Miller JD, Thorp BD, Sreenath SB, McClurg S, et al. Comparison of socioeconomic and demographic factors in patients with chronic rhinosinusitis and allergic fungal sinusitis. Otolaryngol Head Neck Surg. 2015;153:137–43.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Ferguson BJ, Barnes L, Bernstein JM, et al. Geographic variation in allergic fungal rhinosinusitis. Otolaryngol Clin North Am. 2000;33(2):441–9.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Saravanan K, Panda NK, Chakrabarti A, Das A, Bapuraj RJ. Allergic fungal rhinosinusitis: an attempt to resolve the diagnostic dilemma. Arch Otolaryngol Head Neck Surg. 2006;132:173–8.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    deShazo RD, Swain RE. Diagnostic criteria for allergic fungal sinusitis. J Allergy Clin Immunol. 1995;96:24–35.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Ferguson BJ. Definitions of fungal rhinosinusitis. Otolaryngol Clin North Am. 2000;33(2):227–35.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Hutcheson PS, Schubert MS, Slavin RG. Distinctions between allergic fungal rhinosinusitis and chronic rhinosinusitis. Am J Rhinol Allergy. 2010;24:405–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Manning SC, Holman M. Further evidence for allergic pathophysiology in allergic fungal sinusitis. Laryngoscope. 1998;108(10):1485–96.CrossRefPubMedGoogle Scholar
  22. 22.
    Chang YT, Fang SY. Tissue-specific immunoglobulin E in maxillary sinus mucosa of allergic fungal sinusitis. Rhinology. 2008;46:226–30.PubMedGoogle Scholar
  23. 23.
    Wise SK, Ahn CN, Lathers DM, Mulligan RM, Schlosser RJ. Antigen-specific IgE in sinus mucosa of allergic fungal rhinosinusitis patients. Am J Rhinol. 2008;22:451–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Collins M, Nair S, Smith W, Kette F, Gillis D, Wormald PJ. Role of local immunoglobulin E production in the pathophysiology of noninvasive fungal sinusitis. Laryngoscope. 2004;114:1242–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Ragab A, Samak RM. Immunohistochemical dissimilarity between allergic fungal and nonfungal chronic rhinosinusitis. Am J Rhinol Allergy. 2013;27:168–76.CrossRefPubMedGoogle Scholar
  26. 26.
    MacKenzie JR, Mattes J, Dent LA, Foster PS. Eosinophils promote allergic disease of the lung by regulating CD4 Th2 lymphocyte function. J Immunol. 2001;167:3146–55.CrossRefPubMedGoogle Scholar
  27. 27.
    Garro AP, Chiapello LS, Baronetti JL, Masih DT. Rat eosinophils stimulate the expansion of Cryptococcus neoformans-specific CD4() and CD8() T cells with a T-helper 1 profile. Immunology. 2011;132:174–87.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Pezato R, Balsalobre L, Lima M, Bezerra TF, Voegels RL, Gregorio LC, et al. Convergence of two major pathophysiologic mechanisms in nasal polyposis: immune response to Staphylococcus aureus and airway remodeling. J Otolaryngol Head Neck Surg. 2013;42:27.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Bachert C, Gevaert P, Holtappels G, Johansson SG, van Cauwenberge P. Total and specific IgE in nasal polyps is related to local eosinophilic inflammation. J Allergy Clin Immunol. 2001;107:607–14.CrossRefPubMedGoogle Scholar
  30. 30.
    Clark DW, Wenaas A, Luong A, Citardi MJ, Fakhri S. Staphylococcus aureus prevalence in allergic fungal rhinosinusitis vs other subsets of chronic rhinosinusitis with nasal polyps. Int Forum Allergy Rhinol. 2013;3:89–93.CrossRefPubMedGoogle Scholar
  31. 31.
    Bent JP III, Kuhn FA. Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1994;111(5):580–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF, Nicklas RA, et al. American Academy of Allergy, Asthma and Immunology; American Academy of Otolaryngologic Allergy; American Academy of Otolaryngology-Head and Neck Surgery; American College of Allergy, Asthma and Immunology; American Rhinologic Society. Rhinosinusitis: establishing definitions for clinical research and patient care. Otolaryngol Head Neck Surg. 2004;131(6, Suppl):S1–S62.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Patro SK, Verma RK, Panda NK, Chakrabarti A, Singh P. Efficacy of preoperative itraconazole in allergic fungal rhinosinusitis. Am J Rhinol Allergy. 2015;29:299–304.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Rains BM III, Mineck CW. Treatment of allergic fungal sinusitis with high-dose itraconazole. Am J Rhinol. 2003;12:1–8.CrossRefGoogle Scholar
  35. 35.
    Sieberling K, Wormald PJ. The role of itraconazole in recalcitrant fungal sinusitis. Am J Rhinol Allergy. 2009;23:303–6.CrossRefGoogle Scholar
  36. 36.
    Panda NK, Francis AA, Chakrabarti A, Virk RS. Oral itraconazole as an adjunct to steroids in AFRS. Otolaryngol Head Neck Surg. 2012;147:114.CrossRefGoogle Scholar
  37. 37.
    Folker RJ, Marple BF, Mabry RL, Mabry CS. Treatment of allergic fungal sinusitis: a comparison trial of postoperative immunotherapy with specific fungal antigens. Laryngoscope. 1998;108(11 Pt 1):1623–7.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Marple B, Newcomer M, Schwade N, Mabry R. Natural history of allergic fungal rhinosinusitis: a 4- to 10-year follow-up. Otolaryngol Head Neck Surg. 2002;127(5):361–6.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of OtolaryngologyThe University of Texas Southwestern Medical CenterDallasUSA

Personalised recommendations