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.