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BackTable / ENT / Article
Chronic Invasive Fungal Sinusitis Treatment
Audrianna Wu • Updated Sep 30, 2024 • 49 hits
Antifungal medication and surgical intervention are two of the primary treatment options for chronic invasive fungal sinusitis (chronic IFS). However, finding the right balance between medical management and surgery can be difficult, especially due to the delicate nature of the tissues that are typically infected in patients with chronic invasive fungal sinusitis.
Rhinologist Dr. Ashleigh Halderman provides her recommendations for management of chronic invasive fungal sinusitis, beginning with identifying the type of fungi in the patient. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Chronic invasive fungal sinusitis can be caused by a wide variety of fungi, with aspergillus fungi being the most common type seen in patients.
• Dr. Halderman cautions against using high dose steroids when treating patients with acute fungal sinusitis or suspected chronic invasive fungal sinusitis, since it could potentially worsen the patient’s condition.
• Dr. Halderman typically starts pre-operative patients on liposomal amphotericin, a more general type of antifungal treatment.
• While surgical treatment can be a viable option for treating chronic IFS patients, Dr. Halderman often utilizes it only to confirm the fungal specimen causing the infection. When possible, she veers away from aggressively treating chronic IFS through surgery to avoid causing permanent damage to the patient’s tissues.
• After confirming the fungus causing the infection, Dr. Halderman recommends that patients take oral azole medication to target that specific fungus.
Table of Contents
(1) Medical Management of Chronic Invasive Fungal Sinusitis
(2) The Role of Surgery in Chronic Invasive Fungal Sinusitis
Medical Management of Chronic Invasive Fungal Sinusitis
Patients with chronic invasive fungal sinusitis are often infected with aspergillus fungi, but can also be impacted by a wide variety of other fungi. When starting pre-operative patients on antifungal treatment, Dr. Halderman recommends beginning with liposomal amphotericin. She also cautions against using steroid treatment in pre-operative patients who have been diagnosed with AFS, as there have been reports of AFS patient conditions progressing to the more severe chronic IFS condition after implementing even a brief high dose steroid plan.
[Dr. Gopi Shah]
In terms of empiric antifungals, when I think of acute invasive fungal sinusitis, the empiric is amphotericin. For chronic invasive fungal sinusitis, is the empiric antifungal also amphotericin or is this a voriconazole type? What do we usually start patients on?
[Dr. Ashleigh Halderman]
Typically, it's ampho and then they back off depending on speciation.
[Dr. Gopi Shah]
In chronic invasive, are we thinking mucor and the range from mucor to aspergillus to I've even seen just dematiaceous and acute invasive fungal sinusitis. Is it the whole gambit as well in chronic invasive?
[Dr. Ashleigh Halderman]
It's the whole gambit, yes. I think the majority of cases end up being aspergillus, honestly. I think that's the most common, but I've seen it due to dematiaceous as well. Mucor, I'm a little bit less certain about. I remember because I had another case here within the last year. I was corresponding with our IED doctors and I found a paper and I think everything was represented in this series.
[Dr. Ashley Agan]
For the patient who, for that AFS patient where they don't have any sort of neuropathy, they're not losing their vision, but maybe there's just some funny looking spots on the MRI or the CT where you're like, I'm a little bit concerned about this. Do you treat them different in as far as pre-op medications go? I think the patient that we had shared, instead of doing steroids, you had recommended an antibiotic. I don't remember exactly what, but that was part of it.
[Dr. Ashleigh Halderman]
No, maybe an antifungal.
[Dr. Ashley Agan]
I don't remember. Do you?
[Dr. Ashleigh Halderman]
Itraconazole maybe?
[Dr. Ashley Agan]
How do you think? I thought you gave them doxycycline.
[Dr. Ashleigh Halderman] Maybe. Yes. Okay. That would have been the case. To reduce inflammation. Yes. I've really backed away from doing high dose steroids in AFS patients prior to surgery. I think that's what you're talking about. The reason is because even though it's really rare, that conversion from just allergic fungal to invasive has been reported, and it's been reported in individuals on high dose steroids. I really don't do that anymore at all. Pre-op treat them with steroids.
There's been a few people-- This is interesting, but this is a little bit out there. This is not evidence-based, but we have had a few individuals who had really bad AFS and for whatever reason could not get surgery right away. One individual actually was diagnosed with a renal mass. We were like, we know your symptoms are really bothering you, but you need to have this figured out first. In the meantime, what we did, and I got this from Dr. Ryan, was treated them with steroids and itraconazole at the same time for a prolonged course of the itraconazole and a shorter course of the steroids.
Anecdotally, I had a young woman with AFS, who actually first presented with bronchopulmonary aspergillosis. She had been treated with steroids and I think voriconazole or one of the azoles for a really long period of time. They had initial imaging of her sinuses, I think just when she had started the treatment. Then we had gotten repeat imaging and it was remarkably better. It wasn't 100% clear, and you cannot clear this up with just sort of medical treatment. It's a surgical disease process. I actually took her to the operating room and there was still some fungal mucin in there, but it can sort of improve symptoms for people. That's always dicey. You have to balance that.
Obviously, both steroids and antifungals have a lot of side effects, and the antifungals can be damaging to other organs. That's not something that I like to pull out and use other than very specific cases. That has been something we've offered as a non-operative option for some individuals for a short period of time. If you really want to do something to help cut down inflammation, there's not data to really support this, but you could use like a doxycycline and it does exert some sort of anti-inflammatory effects.
Generally, I don't find that AFS cases bleed a whole bunch. They might at first, but once you start sort of getting in there and getting some of that fungal mucin out of there, unless they're acutely infected on top of the AFS, I just don't find that they really bleed that much. I don't think it's necessary to do steroids perhaps.
[Dr. Ashley Agan]
Even just that 2-week, 10-day or 14-day course of steroids, it could be enough to tip someone into chronic invasive?
[Dr. Ashleigh Halderman]
You just never know. The more I've sort of heard of and seen cases of it converting, I've just been like, I can't do this to people. It's like, I guess you have to ask yourself why you would do that, right? Are you doing it so that the surgery is a little bit easier for you? Not to say like that's a-- But like, if that's my only reason, is to make the surgery a little bit easier or maybe safer or something, I can't sort of do that in the face of like possibly causing them to convert. I think with AFS cases, look, if it's really, really hard and you are struggling, staging it as a complete and perfect option. Back out, go back in later, take some time.
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The Role of Surgery in Chronic Invasive Fungal Sinusitis
With today’s advanced anti-fungal medication, there is more time to develop detailed management plans for chronic invasive fungal sinusitis patients and less emphasis on surgical intervention. Dr. Halderman recommends taking advantage of this extra time to approach surgical treatment of chronic IFS patients with caution, especially since many of the affected tissues in these patients are susceptible to permanent damage. Dr. Halderman employs surgery in chronic IFS to confirm the diagnosis and specimen type rather than using it as a corrective treatment option. Once the fungal type is confirmed, she prescribes fungi-specific oral azole medication to control the infection.
[Dr. Ashley Agan]
For patients, let's say you have made the diagnosis, you got tissue confirmation, you have fungus that is invasive within the tissue and you say, okay, this is a chronic invasive fungal sinusitis. What do the next several months look like for that patient, as far as like how long do they need to be on antifungals and what's their surveillance like with you?
[Dr. Gopi Shah]
Also, do you have to go and do like a FESS? Is there any role of opening things up for irrigations or topicals or anything like that after the biopsy?
[Dr. Ashleigh Halderman]
Yes. I think I'll start with that, Gopi, because that's an important discussion point with chronic granulomatous and chronic invasive is how aggressive surgically do you get. I think that we're at this interesting time where in the past, people used to advocate for very aggressive surgical resection of all involved tissue. I've never done that and I don't think that really maybe needs to play a part anymore in the management of these patients. I think that way of thinking and that management was born out of necessity back when amphotericin was non-liposomal and it would cause kidney failure. It was just people couldn't be on it for more than a few days at a time because their organs would start failing. It was a really self-limited option.
Now that we have the liposomal amphotericin and it no longer causes immediate organ failure or in a really rapid time period, we've got a lot more time. I'd say that even more importantly, the azole and the development of those has led to improved medical management of these patients, which has reduced the necessity of being surgically aggressive. In these cases, because of where they tend to go, so orbital apex, orbit, sphenoid, surgical resection, pterygopalatine fossa. Surgical resection would be quite morbid and potentially fatal. You're really in a tough spot there.
We definitely take a more measured surgical approach. I don't think it ever hurts to open things up if this isn't concurrent with like fungal ball or allergic fungal sinusitis. I'm going to open those sinuses up to remove all of the fungal debris that's sitting there on the surface. If there's anything by chance that is necrotic or you're concerned about viability, you could always debride that as well. Mostly you're going in there just to get a diagnosis in my opinion. Some people might disagree and I think some people still go after that really aggressively, but that's just not something that we do here.
Then it's all about getting the specimen the speciation, knowing what it is and putting them on appropriate antifungals. Then the surveillance is imaging based. You're looking to see if this stuff clears up. In my experience, people have been on antifungals typically until maybe a little bit after the imaging sort of resolves. If the imaging never resolves, so long as they're not getting worse, that makes you think that maybe there's something else going on that you need to go back in there. Maybe it's a different fungus that's not being sort of controlled by their current oral antifungal medication. Sometimes like that person I started off talking about, that woman who had intracranial, they're going to be on it for the rest of their lives.
[Dr. Gopi Shah]
For that patient, do they just have like a PICC line or a port and they're doing IV infusion every day?
[Dr. Ashleigh Halderman]
No, that's the beautiful thing about the azoles, is that they're all oral. Voriconazole, itraconazole, propiconazole, all oral.
[Dr. Gopi Shah]
Got you. They're on amphotericin until it speciates and then you can convert to oral.
[Dr. Ashleigh Halderman]
Exactly. Yes. It's just like broad spectrum antibiotics until you can narrow it down.
[Dr. Gopi Shah]
What does that timeframe look like?
[Dr. Ashleigh Halderman]
Months and months and months.
[Dr. Gopi Shah]
How long do you think it usually takes to get that speciation and get them transitioned?
[Dr. Ashleigh Halderman]
Oh, that could take about a week or so. What I've been finding is that a lot of times they will transition them off the ampho quickly. They might be on that for like three to five days or something. Maybe even before they have the speciation with maybe some of the earlier information they can start to put them on. I think posiconazole has been a popular option. They might go ahead and do that. It probably depends on the infectious disease doctor and sort of what's going on with the patient overall as far as like renal function, all that.
[Dr. Ashley Agan]
Just going back to the initial presentation, it sounds like this is usually a unilateral presentation?
[Dr. Ashleigh Halderman]
I have not seen it bilateral, fortunately. I am not aware of any reports of it being bilateral.
[Dr. Gopi Shah]
After they're discharged, when do them back? When do you order that first surveillance imaging?
[Dr. Ashleigh Halderman]
I'll usually see them at about a week just to check in. Mostly that's sort of like a, hey, let's make sure that you've got your other follow-ups and that you're on your medications, and that you understand that you're going to need to be on these. Then typically the repeat imaging is up to ID, and I let them decide that. I probably wouldn't get it earlier than one month and would maybe go about 3 months, 6 to 12 weeks of treatment before doing that, and then go from there. It's a conversation with you and ID.
[Dr. Gopi Shah]
That's an MRI usually?
[Dr. Ashleigh Halderman]
Typically, yes.
[Dr. Ashley Agan]
Are sort of the three main things as opposed to any of the sino-nasal symptoms that they probably didn't have to begin with for this.
[Dr. Ashleigh Halderman]
Correct. Right. It's like the absence of sort of sino-nasal symptoms. I think in a few series of patients, like everybody presented with headache or facial pain.
[Dr. Gopi Shah]
Do those symptoms respond pretty quickly?
[Dr. Ashleigh Halderman]
They do actually. Yes. The woman that I had mentioned who had the severe facial pain for a year prior to presentation, her pain rapidly got better, which was very rewarding and she was grateful.
[Dr. Gopi Shah]
Awesome. This has been a really informative, really great talk. As we round things out, anything that we've missed or anything we need to make sure that we touch on before we let you go?
[Dr. Ashleigh Halderman]
No. I think it's worth just sort of repeating the fact that the question of how aggressive surgically do you need to be is very up in the air right now. I can speak from experience when I say I've not regretted not being more surgically aggressive. I would say that in the majority of patients that I have treated, we've done limited debridement just to get the diagnosis and then really relied on the better antifungals that we have now and in a very prolonged course of treatment. We've not disfigured anybody unnecessarily or blinded them or removed an eye or anything like that and they've survived.
I would say if you're faced with one of these cases, don't swing for the fences necessarily. I think that that's something that we as a field need to really revisit, is the necessity of aggressive surgical treatment in these patients with the new age of antifungals.
Podcast Contributors
Dr. Ashleigh Halderman
Dr. Ashleigh Halderman is an Assistant Professor and practicing ENT specializing in rhinology and skull base surgery in the Department of Otolaryngology at UT Southwestern in Texas.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2024, March 26). Ep. 164 – Chronic Invasive Fungal Sinusitis: Diagnosis & Management [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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