3 Discussion
Noninvasive fungal sinusitis can be categorized as fungal ball,
saprophytic fungal sinusitis, or allergic rhinosinusitis. Fungal balls
are considered thick accumulations of fungal hyphae without invasion.
Computed tomography (CT) is regarded as the gold standard tool for the
functional diagnosis of fungal balls. In this report, CT revealed the
presence of hyperdense fungal hyphae with left frontal-ethmoid-maxillary
sinuses. The noninvasive nature of fungal hyphae is determined by the
absence of bony sinus wall erosions and the absence of intracranial or
intraorbital extension in CT images. Fungal balls usually appear in
unilateral sinuses, and fungal balls affecting multiple sinuses are
rare. In this case, we observed that the fungal balls affected the left
frontal-ethmoid-maxillary sinuses. Females are estimated to have a
greater chance of being diagnosed with fungal balls. In this case, the
patient was a 42-year-old female whose age group also fell under the
high chance of becoming infected with fungal balls.
Earlier studies have demonstrated that nasal obstruction, rhinorrhea,
postnasal drip, nasal bleeding, headache, and facial pain are the major
clinical symptoms associated with fungal balls. In this case, the
clinical symptoms observed are consistent with those of previous
studies, as the patient had major symptoms, such as nasal obstruction on
the left side, left-sided facial numbness, pain on the upper palate of
the left side and headache on the left side. The fungal ball was
predominantly observed in immunocompetent individuals; in this case, the
patient assessment revealed the immunocompetence status of the patient.
The treatment strategy for Fb is based on symptoms, and the standard
treatment guideline indicated for Fb is functional endoscopic sinus
surgery (FESS) if symptoms are present. In this case, the patient was
suggested for FESS surgery considering the distress caused by the
symptoms. Qualitative research analyzing patients’ perceptions of
endoscopic sinus surgery (ESS) revealed that there were significant
levels of concern with patients regarding ESS before surgery. In this
case, the concerns regarding FESS and patient awareness about previous
successful fungal sinusitis cases treated by the First Author through
Ayurveda could have led the patient to approach for an Ayurveda
consultation.
FESS surgery is minimally invasive, and earlier studies have established
that it is a safe and effective intervention for Fb patients. The
complete clearance of fungus from the sinus through FESS requires clear
visualization of the sinus. Even with angled endoscopy, sufficient
visualization of the sinus is challenging. FESS intervention requires
significant skill and expertise and the use of appropriate methods to
achieve safe and effective clearance of fungi. The National Sino-Nasal
Audit revealed adverse effects following ESS (6.6%), predominantly
minor bleeding and major complications (0.4%). There is specific
identification of adverse effects associated with the ophthalmic system.
The adverse effects range from minor complications such as periorbital
ecchymosis and orbital emphysema to major complications such as
extraocular muscle injury, persistent diplopia, orbital hemorrhage, or
hematoma.
In this context, the FESS is important for assessing the utility of the
Ayurvedic medicinal intervention presented in this case. In this case,
stand-alone Ayurveda medicine and ayurveda dietary guidelines reversed
the symptoms within 20 days, and clearance from fungal balls was
observed in CT images at 2 months. Recently, Aksakal (2018) reported
three cases in which ESS was performed for the management of fungal
balls [23]. It was observed that it took 26 weeks, 7 months, and 6
months for those patients to achieve relief or reversal of symptoms
after ESS surgery. Alromaih et al. (2023) reported a case series of 4
patients diagnosed with FB who were only managed with steroids and
topical decongestant medications [24]. At least 6 months are needed
for patients to achieve significant symptom relief. Thus, in our case
report, Ayurvedic interventions resulted in much faster symptom reversal
and greater FB clearance in CT images than did ESS and medical therapy,
as reported in earlier publications. The medical therapy for FBs mainly
includes steroids, topical decongestants and antibiotics. There are
warnings of small but important side effects associated with systemic
steroid use, and side effects such as gastric ulcers, osteoporosis and
immune suppression are observed. It is also important to reduce the use
of antibiotics in the midst of increasing concerns over antibiotic
resistance. In this case, the patient’s follow-up revealed no side
effects from the Ayurvedic intervention. Apart from effectiveness and
safety, it is also important to assess the cost effectiveness of an
intervention and its impact on the overall quality of life of patients.
On enquiry with NABH accredited/Franchise hospitals, the rate for FESS
ranges between Rs. 50000-Rs.60000. The expense is exclusive to other
hospital costs and medicine costs, which can be a burden to the patient
compared with Rs.10,000–12,000, who use ayurvedic interventions. Noon
and Hopkins (2016) reported an unexpected trend in which a significant
number of patients were delayed from undergoing surgery in the UK even
after 5 years of chronic rhino sinusitis diagnosis [25]. This is
reflected in the attempt of the NHS UK to reduce costs. The median
length of hospital stay after surgical intervention for Fb-affected
patients according to the assessment of Garofalo et al. (2016) was 3
days [26]. It is important to analyze the loss of production days,
and the overall burden can be added to a patient’s quality of life. The
Ayurvedic interventions documented in this case report may have
advantages in this context, as they can be cost effective and do not
demand hospitalization compared with the ESS intervention.