Adjuvant itraconazole in the treatment of destructive sphenoid aspergillosis

Paranasal aspergillosis is a potentially progressive continuum of disease, classically described as having four forms: allergic, non-invasive, invasive, and fulminant. The first two have been considered together as extramucosal disease whilst the latter two are both variants of tissue-invasive disease. Sphenoid aspergillosis, given its anatomical location is a more aggressive disease than that found affecting the other paranasal sinuses, even when non-invasive, and may be fatal. This is compounded by the fact that diagnosis is difficult and so may be made late when aspergillosis is consequently more advanced. Intracranial extension may occur via the direct spread of invasive disease or along communicating veins despite intact sinus walls and lack of fungal mucosal penetration. Once this occurs mortality is high. We have successfully treated three cases of destructive sphenoid aspergillosis, two of which had intracranial extension, with surgery and adjuvant anti-fungal chemotherapy including itraconazole. We recommend the use of post-operative itraconazole in all cases of sphenoid sinus aspergillosis. Additionally, when there is evidence of spread to the brain or other adjacent structures we would advocate an initial course of intravenous amphotericin B followed by long-term oral itraconazole.