Fungal sinusitis is not one disease. It is a group of sinus conditions in which fungus plays a part, ranging from a clump of fungus sitting quietly in one sinus to an infection that grows into the tissue within hours or days. The type matters more than anything else, because each one is diagnosed and treated differently.
For the common types, treatment centers on sinus surgery, plus steroid medicines for allergic fungal sinusitis. Antifungal medicine by mouth or IV is used mainly for the invasive types. Antifungal nasal sprays and sinus rinses are compounded on prescription, are not FDA-approved, and research has not shown that they help chronic sinusitis. Bayview Pharmacy does not diagnose sinus conditions or decide whether a medication is right for you.
What is fungal sinusitis?
Fungal spores are in the air nearly everywhere, and most people breathe them in every day without getting sick (CDC). Fungal sinusitis develops when fungus collects in the sinuses, triggers an allergic reaction there, or, usually in people with weakened defenses, grows into the tissue. Doctors sort it into two groups based on that last point: whether the fungus invades the tissue (Deutsch et al., 2019; StatPearls).
- Noninvasive fungal sinusitis stays on the surface. It includes a fungus ball, allergic fungal sinusitis, and fungus growing on crusts in a nose that has had surgery.
- Invasive fungal sinusitis means fungus grows into the sinus lining, bone, or blood vessels. It can be acute, developing over days and sometimes hours, or chronic, developing over months or years.
Types of fungal sinusitis
The table summarizes the main types. It describes how each type is usually handled and is not a treatment plan.
| Type | Who usually gets it | What happens | Usual treatment |
|---|---|---|---|
| Fungus ball | Adults with normal immune systems | A dense clump of fungus collects in one sinus, most often the maxillary sinus behind the cheek, without invading it | Removed during endoscopic sinus surgery |
| Allergic fungal sinusitis (AFRS) | Younger adults with allergies, more often in warm, humid regions | An allergic reaction to fungus causes thick, sticky mucus and nasal polyps | Sinus surgery, then steroid medicines; dupilumab for some patients after surgery |
| Fungus on crusts (saprophytic) | People who have had sinus surgery | Fungus grows on dried mucus and crusts, not on living tissue | Saline rinses and cleaning out the crusts |
| Acute invasive | People with weakened immune systems or poorly controlled diabetes | Fungus grows into tissue quickly and can spread to the eye and brain | Emergency surgery and antifungal medicine by IV, sometimes followed by pills |
| Chronic invasive | Mostly people with normal immune systems | Fungus grows into tissue slowly, over months or years | Surgery and antifungal medicine by IV or mouth |
Fungus ball (fungal ball or mycetoma)
A fungus ball is a tangled mass of fungus, usually in a single sinus. It does not grow into the tissue. Many people have few or no symptoms, and a fungus ball is sometimes found on a scan done for another reason. When symptoms occur, they can include facial pressure or pain, postnasal drip, and a bad smell. A fungus ball in the sphenoid sinus, deep behind the nose, often shows up as headache (StatPearls). Earlier dental work on the upper teeth has been linked to fungus balls in the maxillary sinus (Deutsch et al., 2019).
Allergic fungal sinusitis (AFRS)
Allergic fungal rhinosinusitis is an allergic reaction to fungus in the sinuses, not an infection of the tissue. The reaction produces thick, sticky mucus packed with immune cells, along with nasal polyps that block the sinuses. It is most common in younger adults with allergies (Deutsch et al., 2019). In the United States it is reported most often in the South, including the Southeast and Southwest, and along the Mississippi River basin (Roland et al., 2025). It makes up roughly 6 to 7% of chronic sinusitis overall, with wide variation from region to region (Roland et al., 2025).
Typical signs are long-lasting congestion and polyps that come back despite usual treatment, sometimes improving on steroid pills and then returning when they stop. As mucus builds up, it can widen the sinuses and thin the bone around them, and in some people it pushes on the eye (Deutsch et al., 2019).
Invasive fungal sinusitis
In invasive fungal sinusitis, fungus grows into the lining of the sinuses and can spread to the eye and brain. The acute form, which includes mucormycosis, mainly affects people with weakened immune systems: poorly controlled diabetes (especially diabetic ketoacidosis), chemotherapy or blood cancers, organ or stem cell transplants, or long-term steroid use. It can progress over hours to days, and about half of people with it die even with treatment (Deutsch et al., 2019; StatPearls). The chronic form develops slowly over months or years, mostly in people with normal immune systems, and can be mistaken for a tumor (Deutsch et al., 2019).
Fungal sinusitis symptoms
Many symptoms overlap with an ordinary sinus infection: a stuffy nose, facial pressure, thick drainage, postnasal drip, and a weaker sense of smell. Some patterns make an ENT specialist more likely to look for fungus (Deutsch et al., 2019; StatPearls):
- Symptoms mostly on one side of the face or nose
- A bad smell from the nose, which is reported with a fungus ball and with fungus growing on crusts
- Nasal polyps and thick mucus that keep coming back after treatment, as in allergic fungal sinusitis
- Congestion that does not improve with standard treatment
- Bloody discharge or a growing mass, which can occur with chronic invasive disease
When is fungal sinusitis an emergency?
Get emergency care right away if sinus symptoms come with any of the following, especially if your immune system is weakened or your diabetes is not well controlled (StatPearls; MedlinePlus):
- Black or dark crusts, black discharge, or black, dead-looking tissue in the nose
- Numbness or swelling of the face
- Swelling around the eye, a bulging eye, double vision, or vision loss
- A severe headache, confusion, or a change in behavior
- Fever, especially with a weakened immune system or diabetes
These can be signs of acute invasive fungal sinusitis. It is treated in the hospital with urgent surgery to remove infected tissue and antifungal medicine given by IV, along with control of the underlying problem, such as high blood sugar (StatPearls; MedlinePlus). A nasal spray is not a treatment for it.
Is fungal sinusitis contagious?
No. People are exposed to the fungi that cause fungal sinusitis by breathing in spores from the environment, not by catching them from another person (CDC). The invasive forms can spread within the body, to the eye or the brain, which is why they are treated as emergencies.
How is fungal sinusitis diagnosed?
There is no single test, and symptoms alone cannot tell a fungal sinus infection from a bacterial one. An ear, nose, and throat (ENT) specialist usually combines several steps (Deutsch et al., 2019; StatPearls):
- Nasal endoscopy. A thin camera in the nose shows polyps, thick mucus, crusts, or a fungus ball.
- CT scan. This is usually the first imaging test. A fungus ball often appears as dense or calcified material in one sinus, and allergic fungal sinusitis as dense mucus filling widened sinuses.
- MRI. This is used when invasive disease is suspected, to look for spread toward the eye or brain.
- Lab testing of mucus or tissue. Looking at the material under a microscope shows whether fungus is present and whether it has invaded the tissue. Fungal cultures are often negative, so a negative culture does not rule fungus out. Suspected invasive disease needs a biopsy.
- Allergy blood tests. In allergic fungal sinusitis, the total IgE level is often very high, and tests show allergy to fungi.
For allergic fungal sinusitis, many specialists use the Bent and Kuhn criteria: allergy to fungi, nasal polyps, typical CT findings, thick allergic mucus without tissue invasion, and fungus seen when the sinus contents are stained. A 2025 expert workshop noted that these criteria were built on small, regional groups of patients and suggested a simpler approach based on fungal allergy, a high IgE level, and typical CT findings, while calling for experts to agree on new criteria (Roland et al., 2025).
Fungal vs. bacterial sinus infection
The symptoms overlap, so the two usually cannot be told apart at home. An ENT specialist is more likely to look for fungus when symptoms are mostly on one side, keep coming back, come with polyps and thick mucus that return after treatment, do not improve with standard treatment, or occur in someone with a weakened immune system (Deutsch et al., 2019; StatPearls). Antibiotics treat bacteria, not fungus. The answer comes from an exam, imaging, and lab testing.
Fungal sinusitis treatment
Treatment depends on the type. Your ENT specialist decides which approach fits you.
Fungus ball
A fungus ball is removed during endoscopic sinus surgery, sometimes with the sinus opening widened so it drains well. The Infectious Diseases Society of America (IDSA) guideline says surgery alone can treat it (IDSA, 2016).
Allergic fungal sinusitis
Surgery is the cornerstone. Endoscopic sinus surgery removes the polyps and allergic mucus and opens the sinuses, and medicines alone generally do not control the disease (Roland et al., 2025). After surgery, care usually includes:
- Steroid nasal sprays or steroid sinus rinses. IDSA recommends topical nasal steroids, especially after surgery, to ease symptoms and lengthen the time before the disease returns (IDSA, 2016). Some ENT specialists prescribe a steroid such as budesonide mixed into a saline sinus rinse, which a 2014 review rated an option rather than a recommendation (Gan et al., 2014). Compounded budesonide rinse capsules are not FDA-approved and require a prescription.
- Short courses of steroid pills before and after surgery and for flares. Long-term use is avoided because of side effects (Gan et al., 2014).
- Dupilumab (Dupixent). In February 2026 the FDA approved this injectable medicine for allergic fungal sinusitis in adults and children 6 and older who have had sinus surgery, the first FDA approval for the condition. In a 52-week trial, it improved CT findings and reduced the need for steroid medicines taken by mouth or injection and for repeat surgery compared with placebo (FDA).
- Antifungal pills such as itraconazole, which IDSA suggests for disease that does not respond or comes back quickly, as a weak recommendation based on low-quality evidence, noting they are only partly effective (IDSA, 2016).
Allergic fungal sinusitis often comes back. In a large analysis, about 29% of people with it needed repeat sinus surgery, compared with about 19% of people with other chronic sinusitis with nasal polyps (Roland et al., 2025). Ongoing follow-up with an ENT specialist is the norm.
Invasive fungal sinusitis
Treatment is urgent surgery to remove all infected and dead tissue, often more than once, plus antifungal medicine given by IV and sometimes later by mouth, such as amphotericin B, voriconazole, posaconazole, or isavuconazole, depending on the fungus. Treating the underlying cause, such as high blood sugar or a low white blood cell count, is part of the treatment, and outcomes depend largely on whether that immune problem can be corrected (Deutsch et al., 2019; IDSA, 2016; StatPearls; MedlinePlus). The amphotericin B used for invasive infection is an IV hospital medicine, not a nasal spray, and antifungal nasal sprays have no role in treating invasive disease.
Fungus on crusts after surgery
When fungus grows on crusts in a nose that has had surgery, it is usually managed with saline rinses and cleaning out the crusts, without more surgery (Deutsch et al., 2019; StatPearls).
Do antifungal nasal sprays help fungal sinusitis?
For chronic sinusitis, research has not shown that they help. A 2018 Cochrane review looked at 7 trials of antifungal sprays or rinses in 437 adults, six with amphotericin B and one with fluconazole. None showed better symptoms or quality of life than placebo or no treatment, and the certainty of the evidence was low to very low. Irritation inside the nose may have been more common with the antifungal (Head et al., 2018). The largest of those trials, in which 116 people rinsed with amphotericin B twice a day for 3 months, found no difference from placebo on any measure (Ebbens et al., 2006).
Guidelines follow the evidence. The American Academy of Otolaryngology-Head and Neck Surgery Foundation guideline advises against prescribing topical or systemic antifungals for chronic sinusitis, and the 2021 international consensus statement makes a strong recommendation against topical antifungals (AAO-HNSF, 2025; ICAR-RS, 2021).
For allergic fungal sinusitis, the evidence is thinner still. The Cochrane review found no trials in it. A small randomized study after sinus surgery reported fewer relapses with fluconazole nasal spray, and a pilot study without a comparison group described 16 patients who also took steroid and antifungal pills. A formal review set both aside and gave no recommendation, and none of the guidelines cited here recommends topical antifungals for allergic fungal sinusitis (Khalil et al., 2011; Jen et al., 2004; Gan et al., 2014). Bayview is not aware of any published trial of itraconazole, ketoconazole, miconazole, or clotrimazole nasal sprays or rinses for sinusitis.
Some ENT specialists still prescribe an antifungal nasal spray or rinse for selected patients, and whether one is reasonable for you is your specialist's decision. Bayview prepares them when they are prescribed but does not claim they work, and they should not replace surgery, steroid treatment, or emergency care when those are needed.
Is there an FDA-approved antifungal nasal spray?
No. There is no FDA-approved antifungal nasal spray or sinus rinse, over the counter or by prescription. Antifungal medicines are FDA-approved in other forms, such as pills, IV or injection, skin products, mouth tablets or lozenges, vaginal products, and, for clotrimazole, ear drops (Drugs@FDA). When a provider prescribes an antifungal for the nose, a compounding pharmacy prepares it for that one patient. Compounded preparations are not FDA-approved, and a prescription is required.
If you use any sinus rinse, use distilled or sterile water, or tap water boiled for 3 to 5 minutes and cooled until lukewarm. Untreated tap water can carry organisms that may be safe to swallow but can cause serious infections in the nose. Boiled water can be kept in a clean, closed container for up to 24 hours (FDA).
What does Bayview compound for the sinuses?
On a prescriber's order, Bayview prepares antifungal nasal sprays with itraconazole, ketoconazole, fluconazole, or miconazole, and sinus rinses with itraconazole, fluconazole, or clotrimazole, including combinations with an antibiotic or a steroid. Bayview also prepares amphotericin B and nystatin nasal preparations, budesonide capsules for sinus rinses, and mupirocin nasal preparations. These are compounded medications, they are not FDA-approved, and a valid prescription is required.
How do you get a prescription filled at Bayview?
Start with your provider, usually an ENT specialist, who works out which type of fungal sinusitis you have and decides on treatment. If they prescribe a compounded nasal spray or rinse, they can e-prescribe, fax, or call it to Bayview Pharmacy in Warwick, Rhode Island. Already have a prescription at another pharmacy? You can transfer it to Bayview. We fill and ship to patients in the states where Bayview is licensed, which are listed on our FAQ.
Sources
- Deutsch PG, Whittaker J, Prasad S. Invasive and non-invasive fungal rhinosinusitis: a review and update of the evidence. Medicina (Kaunas). 2019;55(7):319.
- StatPearls (NCBI Bookshelf). Fungal Sinusitis. Updated May 2026.
- Patterson TF, Thompson GR, Denning DW, et al. Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;63(4):e1-e60.
- Roland LT, Damask C, Luong AU, et al. Allergic fungal rhinosinusitis diagnosis, management, associated conditions, pathophysiology, and future directions: summary of a multidisciplinary workshop. Int Forum Allergy Rhinol. 2025;15(6):626-641.
- Gan EC, Thamboo A, Rudmik L, et al. Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations. Int Forum Allergy Rhinol. 2014;4(9):702-715.
- U.S. Food and Drug Administration. FDA approves drug for adult and pediatric patients aged 6 and older with allergic fungal rhinosinusitis. February 2026.
- Head K, Sharp S, Chong LY, Hopkins C, Philpott C. Topical and systemic antifungal therapy for chronic rhinosinusitis. Cochrane Database Syst Rev. 2018;CD012453.
- Ebbens FA, Scadding GK, Badia L, et al. Amphotericin B nasal lavages: not a solution for patients with chronic rhinosinusitis. J Allergy Clin Immunol. 2006;118(5):1149-1156.
- American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical Practice Guideline: Adult Sinusitis Update, summary guide. 2025.
- Orlandi RR, Kingdom TT, Smith TL, et al. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol. 2021;11(3):213-739.
- Khalil Y, Tharwat A, Abdou AG, et al. The role of antifungal therapy in the prevention of recurrent allergic fungal rhinosinusitis after functional endoscopic sinus surgery: a randomized, controlled study. Ear Nose Throat J. 2011;90(8).
- Jen A, Kacker A, Huang C, Anand V. Fluconazole nasal spray in the treatment of allergic fungal sinusitis: a pilot study. Ear Nose Throat J. 2004.
- Centers for Disease Control and Prevention. About Aspergillosis and About Mucormycosis.
- MedlinePlus Medical Encyclopedia. Mucormycosis.
- U.S. Food and Drug Administration. Is Rinsing Your Sinuses With Neti Pots Safe?
- U.S. Food and Drug Administration. Drugs@FDA: FDA-approved drugs.
Frequently asked questions
What is fungal sinusitis?
Fungal sinusitis is a group of sinus conditions in which fungus plays a part. Noninvasive types, such as a fungus ball or allergic fungal sinusitis, stay on the surface of the sinuses. Invasive types, in which fungus grows into the tissue, are less common, and the fast-moving acute form mostly affects people with weakened immune systems. Each type is diagnosed and treated differently.
What are the symptoms of fungal sinusitis?
Many symptoms match an ordinary sinus infection: a stuffy nose, facial pressure, thick drainage, postnasal drip, and a weaker sense of smell. Symptoms mostly on one side, a bad smell from the nose, polyps that keep coming back, or congestion that does not improve with standard treatment make fungus more likely. Black crusts in the nose, facial numbness or swelling, or eye swelling or vision changes need emergency care.
How do you test for a fungal sinus infection?
An ENT specialist usually combines a nasal endoscopy, a CT scan, and lab testing of mucus or tissue under a microscope. MRI and a biopsy are used when invasive disease is suspected. Fungal cultures are often negative, so a negative culture does not rule fungus out. For allergic fungal sinusitis, blood tests often show a high IgE level and allergy to fungi.
How is fungal sinusitis treated?
It depends on the type. A fungus ball is removed with sinus surgery. Allergic fungal sinusitis is usually treated with surgery followed by steroid sprays, rinses, or pills, and since February 2026 the FDA has approved dupilumab for some patients who have had sinus surgery. Invasive fungal sinusitis needs urgent surgery and antifungal medicine by IV or mouth. Your ENT specialist decides which treatment fits you.
Can you smell a fungal sinus infection?
Sometimes. A bad smell from the nose is reported with a fungus ball and with fungus growing on crusts after sinus surgery. A bad smell can also come from other sinus problems, so it is a reason to see an ENT specialist rather than a way to tell what is causing it.
Is fungal sinusitis contagious?
No. People are exposed to the fungi that cause it by breathing in spores from the environment, not by catching them from another person. The invasive forms can spread within the body, to the eye or brain, which is why they are treated as emergencies.
Is fungal sinusitis dangerous?
Noninvasive types, such as a fungus ball or allergic fungal sinusitis, generally have a good outlook with treatment, although allergic fungal sinusitis often comes back. Acute invasive fungal sinusitis is a medical emergency: it mostly affects people with weakened immune systems or poorly controlled diabetes, and about half of people with it die even with treatment.
How can you tell if a sinus infection is fungal or bacterial?
Not from symptoms alone, because they overlap. An ENT specialist is more likely to look for fungus when symptoms are mostly on one side, keep coming back, come with polyps and thick mucus that return after treatment, do not improve with standard treatment, or occur in someone with a weakened immune system. The answer comes from an exam, a CT scan, and lab testing.
Is there an FDA-approved treatment for allergic fungal sinusitis?
Yes. In February 2026 the FDA approved dupilumab (Dupixent), an injectable medicine, for allergic fungal sinusitis in adults and children 6 and older who have had sinus surgery. It was the first FDA approval for the condition. Surgery and steroid medicines remain the core of treatment, and your ENT specialist decides whether dupilumab fits you.
What is allergic fungal sinusitis?
It is an allergic reaction to fungus in the sinuses that leads to thick, sticky mucus and nasal polyps. It is not an infection of the tissue. Treatment usually starts with sinus surgery to clear the mucus and polyps, followed by steroid medicines and saline rinses to help keep it from coming back. A few small studies have looked at antifungal sprays after surgery, but the evidence is limited and guidelines do not include them.
When is fungal sinusitis an emergency?
Invasive fungal sinusitis, where fungus grows into the tissue, can be life-threatening. Get emergency care right away for sinus symptoms with facial numbness or swelling, swelling around the eye or vision changes, black tissue or black discharge in the nose, new changes in behavior or personality, or fever in someone with a weakened immune system. The risk is highest with a weakened immune system or diabetes that is not controlled. It is treated with surgery and antifungal medicine given by IV or mouth, not with a nasal spray.
Do antifungal nasal sprays work for chronic sinusitis?
Research has not shown that they help. In a Cochrane review of seven trials, the four that measured quality of life found no significant improvement, and U.S., European, and international sinus guidelines recommend against antifungal sprays and rinses for chronic rhinosinusitis. A few small studies have looked at them after surgery for allergic fungal sinusitis, but the evidence is limited and guidelines do not include them. Bayview compounds them when prescribed but does not claim they work.
What Bayview compounds for this
Important: Compounded medications are prepared to a prescriber's order for an individual patient. They are not FDA-approved, and the FDA has not evaluated them for safety, effectiveness, or manufacturing quality. This article is educational and is not a substitute for advice from your prescriber or pharmacist.
This preparation contains a controlled substance. Controlled-substance prescriptions carry refill limits, must be e-prescribed, and can only be shipped to states where Bayview holds the required licensure.
Uses discussed here may be off-label, meaning they are not part of any FDA-approved labeling. Off-label use is a decision for you and your prescriber, based on the available evidence.
Veterinary preparations are compounded to a veterinarian's order for a specific animal and are not FDA-approved animal drugs. Never give a compounded human medication to an animal without veterinary direction.
Compounded prescriptions are paid for directly rather than billed through insurance. Most are HSA/FSA-eligible, and many patients submit the receipt to their plan for possible reimbursement. Pricing depends on the strength, dose form and quantity your prescriber orders. Read more about cost and insurance.
Compounded antifungal nasal sprays at Bayview start at $91 for a 12 mL spray. The price depends on the medicine, strength, and amount your provider orders. Compounded preparations at Bayview are cash-priced rather than billed through insurance, and they are generally eligible for HSA and FSA cards. A prescription is required. Do compounding pharmacies take insurance covers this in more detail.
Bayview Pharmacy is a compounding pharmacy in Warwick, Rhode Island, licensed to fill and ship compounded prescriptions for patients in Rhode Island, Massachusetts, Connecticut, New Jersey, New Hampshire, Florida, Maine and Pennsylvania. Prescriptions for New York patients are filled on a limited basis, and controlled substances are not shipped to New York addresses. See every state we ship to.
