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Aspergillus related sinusitis is a fungal infectious disease that, despite its diffusion, is still not well acknowledged to dental operators. Due to the anatomophysiology characteristics of the maxillary sinus, the diagnosis of non-invasive aspergillus sinusitis relies on clinical and imaging signs, and on the medical history of the patient. Here, we present a clinical case describing a fungus ball, which diagnosis resulted particularly difficult, due to the presence of concomitant dental interventions in the same maxillary area. A 50 years-old woman, without any medical issue, came to the private dental practice complaining about nasal discharge from the left side. Dental arch were subjected to several treatments; to better understand the working plan, an orthopantomogram was performed, revealing a radiopacity in the left sinus. The conebeam computed tomography showed the obstruction of the maxillary sinus, and clarified the presence of mycetoma calculus. The patient underwent surgical Caldwell-Luc intervention and mycetoma sampling; the following in-vitro investigations revealed the presence of Aspergillus Niger. The one-year followup showed no recurrence of the infection. The reported case is aimed to underline how mycetoma is a benign condition, still unknown to dentists despite its large diffusion. Moreover, the authors want to highlight that an endodontic treatment can offer a favourable environment to mycetoma formation.
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G. Botticelli
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Annali di stomatologia
fungal sinusitis
Maxillary sinus infection related to Aspergillus: case report and recent updates
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Original Article
2022-08-09
2022-08-09
2019-12-01
2023-12-04
02-05
Ann Stomatol (Roma)
G. Botticelli
2019
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Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
1971-1441
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fungal sinusitis
en
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Maxillary sinus infection related to Aspergillus: case report and recent updates
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                                                                                                       Original article


Maxillary sinus infection related to Aspergillus:
case report and recent updates


Pierpaolo Petrelli1                                           Introduction
Fabiola Rinaldi1*
Sofia Rastelli2                                               Aspergillus sinusitis, firstly reported by Katzenstein et
Gianluca Botticelli2                                          al. in 1983, is an infectious disease that, despite its dif-
                                                              fusion, still presents a challenge in diagnosis, manage-
1
    Department of Innovative Technologies in Medicine         ment, classification, and characterization (1).
    & Dentistry, University of Chieti—Pescara ‘Gabriele       The first organs affected by aspergillosis in the case of
    d’Annunzio’, 66100 Chieti, Italy                          the Head and Neck region are the nasal cavity and para-
2
    Department of Life, Health and Environmental              nasal sinuses.
    Sciences, University of L’Aquila, 67100 L’Aquila, Italy   Aspergillus species are more than 185, but Aspergillus
                                                              Fumigatus, Aspergillus Flavus, and Aspergillus Niger are
                                                              responsible for over 95 % of all infections (2). Symptoms
*Corresponding author:                                        include anterior and posterior nasal discharge, epistax-
Fabiola Rinaldi                                               is, nasal polyps, nasal obstruction, headache, proptosis,
DDS, Oral Surgery Post-Graduate Student, Depart-              anosmia, and snoring (3). Aspergillus genus includes
ment of Innovative Technologies in Medicine & Dentistry,      pathogens without keratolytic enzymes and, therefore,
University of Chieti—Pescara ‘Gabriele d’Annunzio’,           cannot actively penetrate undamaged and intact mucus
66100 Chieti, Italy, fabiola.rinaldi@studenti.unich.it,       membrane or skin (4).
08713554220.                                                  Diagnosis is based on infiltrative or non-infiltrative fungal
                                                              hyphae, sinonasal polyposis, and histopathology with a
Abstract                                                      positive fungal culture of the tissue sampled from surgi-
                                                              cal intervention (5). An early diagnosis, appropriate pre-
Aspergillus related sinusitis is a fungal infectious          and post-operative pharmacological steroids and antifun-
disease that, despite its diffusion, is still not well ac-    gal molecules, an accurate surgical debridement of the
knowledged to dental operators. Due to the anatomo-           polyps, and adequate drainage represent the successful
physiology characteristics of the maxillary sinus, the        key points of the aspergillosis sinusitis treatment (6).
diagnosis of non-invasive aspergillus sinusitis relies        The anatomical position of the paranasal sinus can
on clinical and imaging signs, and on the medical his-        eventually lead to the spread of the infection into the cra-
tory of the patient. Here, we present a clinical case de-     nial cavity, representing a life-threatening complication
scribing a fungus ball, which diagnosis resulted par-         of the aspergillus sinusitis. In particular, the infection can
ticularly difficult, due to the presence of concomitant       spread to orbit due to the bone erosion of the fungal pol-
dental interventions in the same maxillary area. A 50         yps. The infection can run into the middle cranial fossa
years-old woman, without any medical issue, came to           from the superior orbital fissure and optic canal (7).
the private dental practice complaining about nasal           Classification of paranasal sinus Aspergillosis includes
discharge from the left side. Dental arch were sub-           invasive (acute fulminant, chronic invasive, granuloma-
jected to several treatments; to better understand the        tous invasive) and non-invasive (fungus ball and allergic
working plan, an orthopantomogram was performed,              fungal rhinosinusitis) forms, which differ in pathophysiol-
revealing a radiopacity in the left sinus. The cone-          ogy and clinical signs (8).
beam computed tomography showed the obstruction               Due to the anatomical structure of the maxillary sinus
of the maxillary sinus, and clarified the presence of         and the physiology of Schneider’s Membrane, diagnosis
mycetoma calculus. The patient underwent surgical             of non-invasive aspergillus sinusitis relies on clinical and
Caldwell-Luc intervention and mycetoma sampling;              imaging signs and the medical history of the patient.
the following in-vitro investigations revealed the            Here we present a case of fungus ball, which diagnosis
presence of Aspergillus Niger. The one-year follow-           resulted particularly tricky due to the presence of con-
up showed no recurrence of the infection. The re-             comitant dental interventions in the maxillary area.
ported case is aimed to underline how mycetoma is a
benign condition, still unknown to dentists despite its       Case report
large diffusion. Moreover, the authors want to high-
                                                              50 years - old woman, resulted with no pathological con-
light that an endodontic treatment can offer a favour-
                                                              dition in her medical history, came to the private dental
able environment to mycetoma formation.
                                                              practice complaining about nasal discharge from the left
                                                              side. Beyond the nasal discharges, no other symptoms
Keywords: mycetoma, aspergillosis, sinuses, fungal            were referred.
sinusitis.                                                    The left side maxillary teeth presented several treat-

Annali di Stomatologia 2019; X (1-4): 2-5                                                                                      2
    Maxillary Sinus infection related to Aspergillus: case report and recent updates

    ments, so an orthopantomogram (OPG) was taken to                     Successively, the cone-beam computed tomography
    overview the situation.                                              (CBCT) showed the thickening and obstruction of the
    The OPG revealed a radiopacity in the left sinus, well               maxillary sinus and clarified the presence of mycetoma
    demarked and defined but unusual and inconsistent with               calculus (Figure 2). Therefore, the patient was referred
    the dental situation, so any endodontic material and den-            to the local maxilla-facial department for surgical treat-
    tal fixture were excluded (Figure 1).                                ment. Surgical treatment included a Caldwell-Luc inter-




    Figure 1. Initial OPG. On the left side, it is possible to appreciate the sinus opacity as well as the presence of a material
    strongly hyperdense, indicated by the arrow.
    The teeth of the correspondent arches present fixed prosthesis and the presence of several endodontic treatments.




    Figure 2. CBCT reconstruction. Cross sections confirmed the complete sinus obstruction and the presence of an hyperdense
    material.

3                                                                                               Annali di Stomatologia 2019; X (1-4): 2-5
P. Petrelli et al.




Figure 3. One Year follow-up. Teeth have been extracted due to inadequacy to support the crowns and substituted with fixed
prosthetis-implant supported. There was no recurrence of the lesion.




vention with the sinus revision and mycetoma sampling            tis. Innovation in medical technology, including advance-
for culture, which revealed the presence of Aspergillus          ments in radiological imaging and diagnostic endoscopy,
niger.                                                           allowed to define the disease classification, diagnosis,
The OPG performed at a one-year follow-up showed no              and management (8).
recurrence of the infection (Figure 3).                          The mycetoma or fungal ball consists of a slow but con-
Successively the patient revealed she worked in the              tinuous deposition of purulent non-invasive fungal calculi
countryside, and the source of infection was probably            in the paranasal cavities (14). It can present more often
the hay.                                                         unilateral, which is the main difference with allergic fun-
                                                                 gal sinus, even though cases of more cavities have been
Discussion                                                       reported (15). Mycetoma generally occurs in adults, with
                                                                 a preference for the female gender.
The anatomy of the maxillary sinus, which is a cavity,           Mycetoma’s localization usually is more frequent in the
and the histology of the Schneider membrane, make                maxillary sinus and more rarely (5%) in the sphenoid si-
clinical signs of infectious, iatrogenic, or endogenous          nus (16). Patients suffering from mycetoma do not pres-
disease quite similar and challenging for the specialists        ent a compromised immune system nor significant alter-
of the maxillofacial area (dentists, ENTs, maxillofacial         ations in the levels of immunoglobulin or IgG subclasses
surgeons).                                                       (17). However, the slow development of the disease,
Indeed, cysts can expand until they occupy the entire            the quality of the symptoms, and the characteristics of
volume of the sinus (9); an iatrogenic disease caused by         not-invasiveness, make the diagnosis of mycetoma late.
the presence of materials irritating the sinus mucosa pre-       Berry et al. reported 29% of patients receive the diagno-
sents with nasal discharge and unilateral sinusitis (10).        sis within a year from the symptom onset (18). Indeed,
In contrast, infectious diseases cause the thickening of         the quality of the symptoms, which include headache,
the membrane, nasal discharge, and usually present as            cough, and facial pain, are similar to chronic bacterial
bilateral (11).                                                  rhinosinusitis; therefore, instrumental diagnosis is funda-
Recently, fungal rhinosinusitis incidence increased              mental for a differential diagnosis (19).
due to the spread of different pathogens, the aging of           Risks factors associated with the mycetoma are rep-
the population, and the presence of comorbidities and            resented by systemic diseases which can playe a key
chronic diseases, such as diabetes and immunological             role in the onset of the fungal ball, such as anatomi-
diseases requiring long-term steroid therapy immuno-             cal variants (deviation of the nasal septum), Wegener’s
suppressive treatments (12).                                     granulomatosis, asthma, lymphoproliferative diseases,
In a study by Loidolt et al. (13), approximately the fre-        and diabetes (18). In addition, the previous root canal
quency of fungal rhinosinusitis was 10% of all patients          treatments are the dental conditions that can predispose
who underwent surgical treatment due to chronic sinusi-          to mycetoma (4).

Annali di Stomatologia 2019; X (1-4): 2-5                                                                                      4
    Maxillary Sinus infection related to Aspergillus: case report and recent updates

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