Surgery remains the treatment of choice for mycetoma of the paranasal sinuses. Itraconazole has a useful role in reducing both the amount of surgery required and the amount of peri-operative bleeding in allergic aspergillosis, and continuing its use post-operatively for six weeks appears to reduce the recurrence rate (although a case–control study is required to validate this observation). In chronic invasive aspergillosis, itraconazole alone appears to be curative, although liver function tests should be monitored and other interactions considered. Imaging is required to monitor resolution; remineralisation occurs after approximately six months. In fulminant aspergillosis, radical surgery and amphotericin B continue to be the treatments of choice. This review discusses the management of aspergillosis of the paranasal sinuses, and in particular the role of itraconazole antifungal therapy.