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Aspergilloma of Left Maxillary SinusAspergilloma of Left Maxillary Sinus
Report of A Rare CaseReport of A Rare Case
INDIAN DENTAL ACADEMYINDIAN DENTAL ACADEMY
Leader in continuing Dental EducationLeader in continuing Dental Education
www.indiandentalacademy.com

CASE REPORTCASE REPORT
Chief complaint:Chief complaint: Swelling on Left side of the faceSwelling on Left side of the face
& Tingling sensation of upper lip since 1yr.& Tingling sensation of upper lip since 1yr.
HOPI:HOPI:
Gradually increased &Gradually increased &
attained Present sizeattained Present size
with No H/O Pain orwith No H/O Pain or
DischargeDischarge

PMH:PMH: H/O Allergic Rhinitis since 25yrsH/O Allergic Rhinitis since 25yrs
H/O Dry Cough since 30yrsH/O Dry Cough since 30yrs
PDH:PDH:
Oral health check up done 1½yrs backOral health check up done 1½yrs back
Family History:Family History:
Patient’s father died due to TB 45yrs backPatient’s father died due to TB 45yrs back
Personal History:Personal History:
Appetite, Bowl, Bladder, & Sleep were NormalAppetite, Bowl, Bladder, & Sleep were Normal
H/O Wt Loss since 8monthsH/O Wt Loss since 8months

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Clinical ExaminationClinical Examination
General Systemic ExaminationGeneral Systemic Examination
Vital Signs:Vital Signs: Within Normal LimitsWithin Normal Limits

Extra Oral ExaminationExtra Oral Examination
A Ill defined Diffuse Swelling on Left Middle 3A Ill defined Diffuse Swelling on Left Middle 3rdrd
of face extendingof face extending
Anteriorly:Anteriorly:
Upto Ala ofUpto Ala of nosenose
Posteriorly:Posteriorly:
3cms Ant. to Tragus3cms Ant. to Tragus
Superiorly:Superiorly:
UptoUpto Infraorbital MarginInfraorbital Margin
Inferiorly:Inferiorly:
1cm above Occlusal Plane1cm above Occlusal Plane
Lateral wall of Left Nostril is Obliterated, DNS to LeftLateral wall of Left Nostril is Obliterated, DNS to Leftwww.indiandentalacademy.com

On PalpationOn Palpation
–– No rise of Temp.No rise of Temp.
- Non-Tender- Non-Tender
- Firm to Hard- Firm to Hard
- Non Fluctuant- Non Fluctuant
- No Regional- No Regional
LymphadenopathyLymphadenopathy
- Paresthesia of- Paresthesia of
Upper LipUpper Lip

Intra Oral ExaminationIntra Oral Examination
-- Partial ObliterationPartial Obliteration
of Labial & Buccalof Labial & Buccal
Vestibular SulcusVestibular Sulcus
from 22 to 27from 22 to 27
- Mild Tenderness- Mild Tenderness
- Soft in consistency- Soft in consistency
- Mobility of Teeth- Mobility of Teeth
- Poor Oral Hygiene- Poor Oral Hygiene

Provisional DiagnosisProvisional Diagnosis
Malignancy of Left Maxillary Sinus ??Malignancy of Left Maxillary Sinus ??

Differential DiagnosisDifferential Diagnosis
- Tuberculoma- Tuberculoma
- Leproma- Leproma
- Mucormycosis- Mucormycosis
- Histoplasmosis- Histoplasmosis
- Aspergillosis- Aspergillosis
- Cryptococcosis- Cryptococcosis

InvestigationsInvestigations
I.O.P.A.RI.O.P.A.R

Occlusal ViewOcclusal View
Haziness of Left Nasal FossaHaziness of Left Nasal Fossa

PNS ViewPNS View
Haziness with IllHaziness with Ill
defined borders ofdefined borders of
Left Maxillary SinusLeft Maxillary Sinus
extended to Leftextended to Left
lower margin of thelower margin of the
Orbital boneOrbital bone

Coronal view - Plain & Contrast CTCoronal view - Plain & Contrast CT
HomogenouslyHomogenously
enhancing Softenhancing Soft
tissue densitytissue density
mass in themass in the
Left CheekLeft Cheek
with extensionwith extension
into Leftinto Left
Maxillary SinusMaxillary Sinus
& Adjacent& Adjacent
Bony destructionBony destruction

Hematological tests:Hematological tests: Within normal limitsWithin normal limits
Random Blood Sugar:Random Blood Sugar: 224 mg/dl224 mg/dl
ESR:ESR: 28mm/hr28mm/hr

Incisional BiopsyIncisional Biopsy
Histopathological Findings:Histopathological Findings:
Presence of Granulomatous tissue withPresence of Granulomatous tissue with
Caseation Necrosis surrounded byCaseation Necrosis surrounded by
Macrophages, Epitheloid Cells & was AFBMacrophages, Epitheloid Cells & was AFB
NegativeNegative

Histopathological FindingsHistopathological Findings
 Septate HyphaeSeptate Hyphae
 Uniform in diameterUniform in diameter
 454500
Angle BranchingAngle Branching

Final DiagnosisFinal Diagnosis
Aspergilloma of Left Maxillary SinusAspergilloma of Left Maxillary Sinus

ManagementManagement
Management of DMManagement of DM
Surgical ExcisionSurgical Excision
Antifungal therapyAntifungal therapy
Amphotericin B (0.3mg/Kg body wt over 4-8hrs I.V.)Amphotericin B (0.3mg/Kg body wt over 4-8hrs I.V.)
Itraconazole (100-200mg in single or divided doses)Itraconazole (100-200mg in single or divided doses)

DiscussionDiscussion
 Aspergillus is a common Saprophyte of Soil & DecayingAspergillus is a common Saprophyte of Soil & Decaying
Organic MaterialOrganic Material
 More than 185 SpeciesMore than 185 Species
 95% of Infections by A.Fumigatus95% of Infections by A.Fumigatus // FlavusFlavus // NigerNiger
 Majority of Cases(Majority of Cases( Invasive & Non-InvasiveInvasive & Non-Invasive))
causedcaused by A.Fumigatusby A.Fumigatus
A.FlavusA.Flavus→→ InvasiveInvasive DiseaseDisease inin ImmunosuppressedImmunosuppressed PatientsPatients

Aspergillus is aAspergillus is a
 Filamentous Fungus with Septate Hyphae,Filamentous Fungus with Septate Hyphae,
 Uniform in diameterUniform in diameter
 Dichotomous 45Dichotomous 4500
Angle BranchingAngle Branching
 Reproduces as Asexual ConidiaReproduces as Asexual Conidia
 Spores (Spores (2-3µm2-3µm)Transmitted by Air borne Conidia)Transmitted by Air borne Conidia
Hyphae Invade local Blood VesselsHyphae Invade local Blood Vessels→→ IschemicIschemic
Tissue Necrosis & Bony DestructionTissue Necrosis & Bony Destruction
Aspergillus often presents with Vague Complaints &Aspergillus often presents with Vague Complaints &
-ve Clinical findings, making Diagnosis Difficult-ve Clinical findings, making Diagnosis Difficult

Aspergillus Infection of the Sinuses maybeAspergillus Infection of the Sinuses maybe
1. Aerogenic1. Aerogenic
Spores are Inhaled directly into AntrumSpores are Inhaled directly into Antrum
2.2. IatrogenicIatrogenic
Spores enter the AntrumSpores enter the Antrum
via an Oroantral communication,via an Oroantral communication,
following Extraction/ R.C.T.following Extraction/ R.C.T.
Spores Colonize the Maxillary Sinus &Spores Colonize the Maxillary Sinus &
Multiply in Anaerobic conditionsMultiply in Anaerobic conditions

 Paranasal Sinus Aspergillosis Includes aParanasal Sinus Aspergillosis Includes a
Spectrum of Disease Classically Described toSpectrum of Disease Classically Described to
be 4 typesbe 4 types
1. Allergic1. Allergic
2. Non-Invasive2. Non-Invasive, Benign Saprophytic, Benign Saprophytic
InfectionsInfections
3. Invasive3. Invasive, Slow Progressive but, Slow Progressive but
Destructive Infections &Destructive Infections &
4. Fulminant4. Fulminant, Rapidly Progressive, Rapidly Progressive
Infections usually affects ImmunocompromisedInfections usually affects Immunocompromised
PatientsPatients

Allergic Aspergillosis sinusitisAllergic Aspergillosis sinusitis
 First Described byFirst Described by Katzenstein et.alKatzenstein et.al..
 Young AdultsYoung Adults with Asthma, Analogous to Allergicwith Asthma, Analogous to Allergic
Bronchopulmonary AspergillosisBronchopulmonary Aspergillosis
 Does not respond to Conventional MedicalDoes not respond to Conventional Medical
TreatmentTreatment
 Unique Feature isUnique Feature is Expansile NatureExpansile Nature of theof the
Inflammatory Process, result inInflammatory Process, result in Facial DeformityFacial Deformity
 On Radiographic Evaluation, presents with DiffuseOn Radiographic Evaluation, presents with Diffusewww.indiandentalacademy.com

 Tissue Invasion is Not a CommonTissue Invasion is Not a Common
CharacteristicCharacteristic
 Scattered Aspergillus Hyphae in PaleScattered Aspergillus Hyphae in Pale
Eosinophilic or Basophilic Mucin in whichEosinophilic or Basophilic Mucin in which
SloughedSloughed Respiratory Epithelium,Respiratory Epithelium,
Eosinophils, and Charcot-Leyden CrystalsEosinophils, and Charcot-Leyden Crystals
may be seenmay be seen
 Surgical Drainage of the Sinuses followedSurgical Drainage of the Sinuses followed
by Corticosteroid Treatmentby Corticosteroid Treatmentwww.indiandentalacademy.com

AspergillomaAspergilloma
 Fungus BallFungus Ball of Aspergilli present in aof Aspergilli present in a SinusSinus, usually, usually
the Maxillary Antrumthe Maxillary Antrum
 On Radiographic EvaluationOn Radiographic Evaluation Radiodense FociRadiodense Foci inin
Association with Homogeneous OpacificationAssociation with Homogeneous Opacification
 Foci are a result ofFoci are a result of Central NecrosisCentral Necrosis within thewithin the
Fungal MassFungal Mass
 Histology shows Tangled Mycelium of Aspergilli withHistology shows Tangled Mycelium of Aspergilli with
Little Inflammatory ResponseLittle Inflammatory Response

 Hyphae are arranged inHyphae are arranged in Concentric LayersConcentric Layers
like Onion Ringslike Onion Rings
 Hyphae stain poorly with Haematoxylin &Hyphae stain poorly with Haematoxylin &
EosinEosin
 ConidiophoresConidiophores may be seenmay be seen
 Responds well to Drainage of the SinusResponds well to Drainage of the Sinus

Invasive AspergillosisInvasive Aspergillosis
 Occurs in Patients without Obvious ImmuneOccurs in Patients without Obvious Immune
DeficiencyDeficiency
 Clinically, as an Enlarging Mass in theClinically, as an Enlarging Mass in the
Cheek, Orbit, Nose, and Paranasal SinusesCheek, Orbit, Nose, and Paranasal Sinuses
regionregion
 ProptosisProptosis is often a Prominent Featureis often a Prominent Feature
 Inflammatory processInflammatory process Extends Beyond theExtends Beyond the
Bony WallsBony Walls of the Sinuses into the Softof the Sinuses into the Soft
Tissues of the Cheek & OrbitTissues of the Cheek & Orbit

 On Radiographic Evaluation, presents withOn Radiographic Evaluation, presents with
OpacificationOpacification of the Sinus with possibleof the Sinus with possible
added evidence ofadded evidence of Bony DestructionBony Destruction
 Aspergillus Hyphae areAspergillus Hyphae are ScantyScanty and notand not
easily seen with Routine Stains, Appearingeasily seen with Routine Stains, Appearing
asas Holes in Gaint CellsHoles in Gaint Cells, but can be Easily, but can be Easily
Identified withIdentified with Fungal StainsFungal Stains
 Surgery, Systemic AntiFungal TreatmentSurgery, Systemic AntiFungal Treatment
are requiredare required

Fulminant AspergillosisFulminant Aspergillosis
 First recognised inFirst recognised in 19801980
 Clinical FeaturesClinical Features
- Prominent- Prominent Non-TenderNon-Tender FacialFacial CutaneousCutaneous
ErythemaErythema && OedemaOedema are Early Manifestationsare Early Manifestations
-- UlcerationUlceration of theof the Nasal MucosaNasal Mucosa
-- DestructionDestruction of theof the Inferior TurbinatesInferior Turbinates

 Infection will Progress with DestructionInfection will Progress with Destruction
of the Sinuses, Angio-invasion &of the Sinuses, Angio-invasion &
Extension into the Orbit & BrainExtension into the Orbit & Brain
 Little Tissue ReactionLittle Tissue Reaction
 Hyphae are HaematoxyphilicHyphae are Haematoxyphilic
 Surgery & Systemic AntiFungal TreatmentSurgery & Systemic AntiFungal Treatment
usually Requiredusually Required

ConclusionConclusion
This is to Highlight that, Though a RareThis is to Highlight that, Though a Rare
Entity, Aspergillosis should be kept inEntity, Aspergillosis should be kept in
Mind in cases of any Swellings in RelationMind in cases of any Swellings in Relation
to Maxillary Sinus with Nonspecificto Maxillary Sinus with Nonspecific
Symptoms.Symptoms.

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