Current therapeutic protocols for chronic granulomatous fungal sinusitis

BACKGROUND: The treatment of chronic granulomatous fungal sinusitis (CGFS), a rare form of invasive fungal sinusitis, is controversial. AIM: To assess the response to postoperative antifungal therapy in patients with CGFS and suggest an effective treatment protocol. METHODOLOGY: Clinical records of patients with CGFS who had undergone excisive surgery followed by antifungal therapy were reviewed to assess current disease status. RESULTS: Fourteen male and 4 female patients were diagnosed with CGFS, based on typical histopathological and fungal smear/ culture results. Aspergillus flavus was isolated from 88.9% cases. Stage 1 patients had resectable sinonasal disease, stage 2 had additional spread to orbit/palate and stage 3 had extensive disease. Follow-up ranged from 6 months to 8 years. Residual disease was seen in all but one patient who received amphotericin B as first line therapy and in none of those who received itraconazole or voriconazole. Even those who received azoles as second line therapy were disease free at last follow-up. CONCLUSION: Surgery followed by itraconazole or voriconazole for Stage 1 and 2 disease and voriconazole for stage 3 disease is recommended for a good outcome. Amphotericin B is not recommended as first line therapy for CGFS.