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Tearing is a frequently encountered chief complaint in an ophthalmologist's office. Certain associated atypical symptoms may warrant further workup. The authors present a case of a patient presenting with painful tearing which elicited further evaluation with CT imaging. This revealed a maxillary sinus fungus ball as the cause for the patient's tearing.

Objectives/hypothesis: Fungus balls are a common disease of the paranasal sinuses, usually involving the maxillary sinus. To clarify the pathology, we analyzed patients treated for maxillary sinus fungus balls to see whether the latter correlated with dentogenic factors., Study Design: Retrospective case analysis., Methods: Cases of maxillary sinus fungus balls diagnosed between January 2000 and December 2013 were analyzed retrospectively. Patients' charts were reviewed for diagnosis, gender, and age. Paranasal sinus computed tomography (CT) scans were reviewed according to the side of the fungus ball, calcifications/opacifications, and dentogenic factors., Results: In 98/102 patients (96.1%), 157 dentogenic factors could be identified on the side affected by a fungus ball. On the contralateral healthy side, there were 125 dentogenic factors. In four (3.9%) of the patients, no dentogenic pathology was identified on the CT scan. The presence of dentogenic factors (regardless of number) was significantly associated with a fungus ball compared to the healthy side (P = .024, χ(2) test, odds ratio: 2.72 [95% confidence interval: 1.02-7.23])., Conclusions: Dentogenic factors regardless of type potentially correlate with the presence of maxillary sinus fungus ball. Unlike the overall presence of dentogenic factors, the particular dentogenic factors in an individual patient do not significantly influence the development of fungus balls. After diagnosis of dentogenic pathology in penetrated maxillary sinus floors, patients should be closely monitored and informed about their higher risk of developing a fungus ball., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Invasive sino-orbital fungal infections are life-threatening complications of immunonosupression that are difficult to treat. Currently there are no standard treatment guidelines. The most widely accepted therapy includes parenteral anti-fungal therapy and surgical debridement of sinuses with orbital exenteration, a procedure that is not only disfiguring, but may increase morbidity. Injection of retrobulbar Liposomal Amphotericin B (L-AMB) is an alternative approach that provides local administration to infected tissues. The adjunct use of anti-fungal retrobulbar injections not been extensively reviewed in treating sino-orbital infection. We are reporting the multimodal approach of using L-AMB retrobulbar injections in combination with sinus debridement, intravenous (IV) anti-fungal therapy, and hyperbaric oxygen (HBO) for the management of sino-orbital infection., Method & Results: Review of literature of 12 cases and retrospective evaluation of one patient with sino-orbital Aspergillus flavus infection on chemotherapy for T-cell acute lymphocytic leukemia treated with retrobulbar Amphotericin B, IV anti-fungal agents, and hyperbaric oxygen therapy. Clinical characteristics, radiographic features, management techniques, and clinical outcomes are described., Conclusion: Retrobulbar Amphotericin B injection may be an effective adjunct to hyperbaric oxygen and parenteral anti-fungals in the control of sino-orbital fungal infections.

Chronic invasive aspergillosis of the sinus is frequently fatal in the absence of early surgical and chemotherapeutic intervention because of its invasion of vascular tissue. We attempted to control a case of inoperable invasive aspergillosis of the sinus with micafungin and itraconazole oral solution. We prescribed a daily oral dose of 400 mg of itraconazole, which is twice the usual dose, and monitored the serum concentration of the drug. Finally, we were able to control the spread of the lesion. This case indicates that combination therapy with micafungin and a daily dose of 400 mg itraconazole oral solution is an alternative treatment strategy for inoperable invasive aspergillosis of the sinus., (Copyright © 2014 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Introduction: Sinus aspergillosis is a potential complication after root canal therapy of antral teeth. Indeed, zinc oxide-eugenol cement overfilling in the sinus may promote fungal infection. Moreover, if sinus aspergillosis triggers chronic sinusitis with aspergilloma, it may also lead to invasive phenomena, especially for immunocompromised patients., Methods: We reported a sinus aspergillosis case of a patient treated with infliximab (Remicade; Janssen Biologics BV, Leiden, Netherlands). The purpose of this article was to explore the mechanisms of this pathosis, especially the impact of the root canal sealer overextension, which is a contributing factor for fungal infection. The surgical management and the follow-up are also described., Results: Six months after surgery, the patient showed no clinical signs and presented with a healthy and airy right maxillary sinus on the computed tomography scan., Conclusions: In conclusion, prevention and screening of aspergillosis of maxillary sinus may be considered before starting an anti-tumor necrosis factor alpha therapy., (Copyright © 2015 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Cutaneous aspergillosis is a common systemic mycosis affecting immunosuppressed patients. Here, we describe a novel morphological type of cutaneous aspergillosis in a young immunocompetent woman who presented with a chronic history of multiple nodules and discharging sinuses over left side of the face, mimicking cervicofacial actinomycosis. Skin biopsy showed granulomatous inflammation, and of septate fungal hyphae with acute-angled branching, morphologically resembling Aspergillus. This was confirmed on fungal culture as Aspergillus flavus.

The Onodi cell is a pneumatized posterior ethmoid cell located laterally and superiorly to the sphenoid sinus and closely related to the optic nerve. A mucocele is a benign, expansile, cystlike lesion of the paranasal sinuses that is filled with mucoid secretion. Therefore, optic neuropathy caused by an infected mucocele in an Onodi cell is uncommon. Furthermore, fungal infection superimposed on an Onodi cell mucocele is extremely rare and has not been reported previously. Here, we describe the first case of fungal ball within Onodi cell mucocele causing visual loss, which was completely removed via transnasal endoscopic approach.

We report a case with review of literature of actinomycosis accompanied with aspergillosis arising in unilateral maxillary sinus, in which it was completely cured after endoscopic sinus surgery and short term antibiotic therapy. To the best of our knowledge, this is the first case report in literature reporting actinomycosis in combination with aspergillosis in the paranasal sinus. Also, we suggest short term antibiotic therapy within one month may be sufficient if the surgical opening of paranasal sinus involved by actinomycosis could be well preserved., (Copyright © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Maxillary antrolithiasis is characterized by masses of tissue of endogenous or exogenous origin that calcify within the maxillary sinuses. Aspergillosis is a fungal disease in which the maxillary sinus is a primary site of infection. Aspergillosis mycetoma, its noninvasive form, is the most prevalent modality of the disease in the maxillary sinuses. In approximately half of the cases reported in the literature, calcification of the fungal mycelia, which later became antroliths, was verified. This article reports a rare case of the accidental discovery of a maxillary antrolith associated with noninvasive aspergillosis in an immunocompetent and asymptomatic 56-year-old woman. The diagnosis and therapeutic procedures used in treating the patient are discussed as well as the probable iatrogenic origin of the fungal pathology.

Objective: We report an extremely rare case of a fungus ball within a mucocele of the sphenoid sinus and infratemporal fossa., Case Report: A 62-year-old woman was referred for evaluation of a mass lesion in the left sphenoid sinus and infratemporal fossa. Endoscopic examination of the nasal cavity was unremarkable. Computed tomography showed a non-enhancing, expansile mass with calcifications in the sphenoid and infratemporal fossa; T2-weighted magnetic resonance imaging revealed marked hypointense signals within the sphenoid sinus mass, with an intermediate signal intensity. A presumptive diagnosis of a mucocele was made. During surgery, a profuse amount of yellow fluid was drained from the mucocele. Clay-like material was noted within the mucocele, corresponding to the hypointense magnetic resonance imaging signals; this was identified as aspergillus on histopathological examination. Radiological findings for a fungus ball within a mucocele can be similar to those for allergic fungal sinusitis, which shows mixed low and high attenuation on computed tomography and low-signal intensity on T2-weighted magnetic resonance imaging, within an expansile, cystic lesion., Conclusion: Although an association between a fungus ball and a mucocele is rare in the paranasal sinuses, this disease entity should be considered in the differential diagnosis of expansile, cystic sinus lesions.

Aspergillosis, which was first discovered in late 19th century, is a relatively rare disease in the sinuses. In recent years, a number of invasive aspergillosis infections of the maxillary sinus in immunocompromised patients, as well as the non-invasive form of the disease, have been reported. They were caused by the materials used in endodontic treatment, like gutta-percha, antrolith and by foreign bodies. This paper reports a case of aspergillosis in the maxillary sinus of an immunocompromised patient. It is associated with a root fragment after a much earlier tooth extraction.

Objective: Invasive sino-orbital aspergillosis in immunocompetent patients is a rare clinical entity and often misdiagnosed. Invasive sino-orbital aspergillosis is potentially fatal; however, mortality may be avoided with timely treatment. Presently, there are no universal guidelines for its treatment. We present the clinical features, treatment, and outcome in 15 cases of invasive sino-orbital/orbital aspergillosis in healthy individuals., Design: Retrospective case series., Participants: Fifteen cases of invasive sino-orbital/orbital aspergillosis in immunocompetent individuals., Methods: We retrospectively analyzed all patients with sino-orbital/orbital aspergillosis who were treated at the Dr. Rajendra Prasad Center for Ophthalmic Sciences between June 1999 and September 2009. Diagnosis was based on histopathologic documentation of tissue invasion by septate fungal hyphae with acute angle branching and presence of granulomatous inflammation., Main Outcome Measures: Treatment outcome in terms of patient survival, resolution of symptoms, and resolution of orbital mass on imaging., Results: Fifteen patients (11 male and 4 female) were studied. Mean age of patients was 35 years. One patient declined treatment. Surgery was performed for orbital disease in 6 patients. Medical therapy consisted of intravenous amphotericin B followed by itraconazole in 10 patients, itraconazole alone in 2 patients, and voriconazole followed by itraconazole in 2 patients. Eleven patients are alive without recurrence at a median follow-up of 20 months. Of these patients, 5 had residual mass on imaging at last follow-up. One patient died of progressive disease., Conclusions: This is a large case series of orbital aspergillosis reported in healthy individuals. The role of orbital surgery is not clear in treatment of this entity and requires further evaluation. Newer antifungal agents alone seem to be effective in controlling the infection., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate potential differences in clinical presentation, histopathology, and outcomes of chronic invasive sinus aspergillosis (CISA) based on geographic region and species of Aspergillus isolated., Materials and Methods: A retrospective analysis of published cases of CISA with a comparison of North American and worldwide cases comprised a systematic search of the English language literature. Thirty-four articles were identified detailing 15 North American and 76 global cases of CISA with cranio-cerebral extension in clinically immunocompetent patients., Results: North American patients with CISA were older, had a more rapidly progressive course, and appeared to have higher rates of treatment failure and mortality. Anatomic distribution and presenting symptoms were similar between the two groups. North American cases were mostly due to A. fumigatus, while A. flavus was the predominant pathogen worldwide. While granulomatous inflammation was a rare observation in North American cases, it was seen in the majority of cases worldwide. CISA due to A. fumigatus was encountered in older adults, was associated with a chronic inflammatory response, an accelerated clinical course, and a trend toward treatment failure and higher mortality. Patients with A. flavus were younger, demonstrated granulomatous inflammation, and pursued an indolent, clinically responsive course., Conclusion: Observed differences in clinical presentation, histopathology, and outcome might involve a complex interplay between the human host, Aspergillus species, and local climatic conditions.

Purpose: Aspergillus species is found worldwide and does not normally cause disease. However, when the immune system is compromised, it can invade many organs and be responsible for severe disease. The authors present cases with both classical and atypical features of ophthalmic aspergillosis., Methods: Case series of three patients., Results: All patients were female and had a long history of methylprednisolone use. The first two presented with endogenous endophthalmitis. One case was unilateral with a classical presentation of endophthalmitis. The other presented with a very severe bilateral acute retinal necrosis like syndrome. General work-up revealed disseminated disease in both cases. The diagnosis was made by serum immunologic testing in one case and after direct examination and culture from vitrectomy in the other. Despite intense antimycotic therapy, both patients died. The third patient presented with a unilateral progressive painful orbital apex syndrome. An orbital lesion was demonstrated by computed tomography scan and was unresponsive to methylprednisolone. Diagnosis of sino-orbital syndrome was made on biopsy. The lesion responded poorly to different antimycotic therapies, invaded the chiasma, and the patient lost all visual acuity., Conclusions: This case series illustrates that ophthalmic aspergillosis can present acutely with a devastating intraocular inflammation or more indolently in the setting of sino-orbital aspergillosis. Both forms have a poor visual prognosis and the systemic form is frequently associated with a fatal outcome.

A case of invasive aspergillosis (IA) of paranasal sinuses, lung and brain with a fulminant fatal outcome is reported. A 43-year-old man with a history of skin carcinoma of the nasal region and a course of systemic corticosteroids, presented with symptoms of lung infection. Aspergillus fumigatus was cultured from respiratory and nasal samples. Erosion of adjacent bones of the nasal cavity was acknowledged, but no sinus surgery was performed. A computed tomography of the thorax showed thick-walled cavities of different sizes with air and scarce fluid levels in both lungs. Treatment with voriconazole was administered. The patient deteriorated in the ensuing 2 weeks because central nervous system involvement was observed. No aggressive surgical resection was performed and the patient died 2 weeks later. IA was not confirmed by histopathology because no necropsy was performed.

Invasive aspergillosis (IA) originating from the paranasal sinuses can cause an intracranial growth mainly along the skull base and larger vessels. This study reports our experience in the diagnosis and treatment of a series of patients with IA. A retrospective chart review of four patients with chronic invasive intracranial aspergillosis was performed. Clinical signs, physical examinations, radiographs, histological samples, and outcome were demonstrated. The patients demonstrated different symptoms like exophthalmus, ophthalmoplegia, loss of vision, and hypaesthesia of the ophthalmic and maxillary nerve. Computed tomography and MRI revealed extensive sino-orbital and skull base lesions. The patients were treated with aggressive endonasal debridement, intravenous antifungal agents and daily irrigations with antimycotic suspensions. Furthermore, we applied hyperbaric oxygenation. Two patients died from complications due to subarachnoidal hemorrhage and accompanied complications respectively. Despite the high mortality rate patients with an invasive aspergillosis can be effectively treated in some cases by an early and rigorous treatment schedule using all surgical and conservative therapeutic options.

Purpose: Although rare, invasive aspergillosis with intracranial spread usually is fatal and necessitates prompt diagnosis and treatment. We describe the prognoses for survival and vision in 3 consecutive patients with vision-threatening invasive sino-orbital aspergillosis., Methods: A case series of 3 patients, with review of treatments and outcomes., Results: Three diabetic patients presented with significant eye pain and headache, followed by progressive ophthalmic symptoms including vision loss and limitation of ocular motility. Histologic examination showed numerous hyphae of Aspergillus fumigatus. Following early diagnosis and surgical debridement, 1 patient (case 1) showed vision improvement, from counting fingers to 20/20. The other 2 patients, who were initially treated with corticosteroids after presumptive diagnoses of nonspecific orbital inflammation, showed no recovery of vision from no light perception, and 1 (case 3) died of massive intracranial spread and side effects of antifungal agents caused by delayed diagnosis and long-term use of corticosteroids., Conclusions: Invasive sino-orbital aspergillosis with intracranial invasion often may resemble inflammatory conditions. Early diagnosis and surgical intervention are required to improve vision and survival. Repeated biopsies often are necessary to rule out fungal sinus infection before considering steroid use, especially in diabetic patients.

The present study reviews the literature concerning the surgical treatment of Aspergillus mycetoma (AM) in the last 20 years to identify a gold standard surgical technique. Aspergillus mycetoma of the maxillary sinus, or mycetoma (fungus ball), is a noninvasive or extramucosal mycotic infection. Surgical removal of the sinus fungal masses to ensure drainage and aeration is performed using the traditional Caldwell-Luc (CL) procedure or endoscopic sinus surgery (ESS). Results of this review suggest that the gold standard surgical technique for AM is ESS with middle meatal antrostomy. General or local antifungal drugs are not indicated. Combined approach with an intraoral surgical access from the anterolateral wall of the maxillary sinus has to be reserved for selected cases in which ESS doesn't permit complete extraction of all fungal concretions or foreign bodies. The CL procedure should be avoided, because it has detrimental consequences for sinus physiology.

We report the case of an immunocompetent, 39 year old male who presented with diplopia and diffuse headache. The CT scan demonstrated the presence of a sizeable mass that took over the nasal cavity, the right maxillary sinus, the sphenoid and ethmoid sinus, extending to the sellar and suprasellar region, and eroding the adjacent bones. The patient also underwent MRI and endoscopic sinus surgery. Biopsy of the suspected tissue for pathology and culture demonstrated Aspergillus fumigatus.

Objectives/hypothesis: Sinonasal invasive aspergillosis (IA) is an aggressive fungal infection with high mortality rates. It commonly develops in immunocompromised patients, often after bone marrow transplantation (BMT). Aggressive surgical debridement by an external approach has been considered a central element of treatment. We describe our experience in endoscopic management of IA in BMT patients in a retrospective study., Methods: Charts of BMT patients with IA in the past 5 years were reviewed. Demographic data, primary disease, comorbidities, signs and symptoms, blood test results, preparation for surgery, surgical technique, and outcome were recorded., Results: Fourteen BMT patients, age ranging from 3 to 56 years, had sinonasal IA. The primary disease was acute myelogenous leukemia in 6, acute lymphoblastic leukemia in 3, chronic myeloblastic leukemia in one, severe combined immunodeficiency disease in 2, and myelodysplastic syndrome in 2 patients. Diagnosis was made by physical examination, biopsy, culture, and computed tomography scan. Treatment, including aggressive endoscopic debridement, a systemic antifungal medication, and local irrigations of amphotericin-B enabled eradication of IA in all patients. Seven patients required two or more operations. None required orbital exenteration or craniotomy. Six patients died of the primary illness or of comorbidities with no evidence of residual disease. Eight patients are alive., Conclusion: Early detection of IA in BMT patients enables aggressive treatment before the disease spreads into the orbit or brain. Proper preoperative preparation facilitates safe endoscopic surgery in patients with severe bleeding tendencies. Although sinonasal IA is lethal, endoscopic surgery is feasible and efficient, enabling excellent local control.

Long-term outcomes (mean 38+/-17 months) were evaluated in 27 dogs with sinonasal aspergillosis after successful medical treatment using intranasal infusions of 1% or 2% enilconazole (1%, n=15; 2%, n=12). Long-term outcomes with both treatment protocols were good, with half of the dogs being asymptomatic throughout the follow-up period. The remaining dogs showed mild clinical signs compatible with chronic rhinitis/sinusitis. These clinical signs were interpreted as chronic lymphoplasmacytic rhinitis/sinusitis and episodes of bacterial rather than fungal infection. Three dogs had confirmed reinfection or relapse 2 to 36 months after clinical resolution.

Sino-orbital aspergillosis in a 61-year-old male with uncontrolled non-insulin dependent diabetes mellitus presented with three months history of left ear pain, left side headache with mucopurulent nasal discharge and one week history of progressive swelling and pain with difficulty in opening of the left eye and sudden loss of vision. In spite of surgical debridement and medical management with amphotericin B and itraconazole his visual outcome was poor and the infection was unabated at one month follow up.

Miller-Fisher syndrome (MFS) typically presents with ophthalmoplegia, ataxia, and areflexia. Atypical MFS additionally includes bulbar impairment, affection of the limbs, or abortive presentations. Mostly, MFS follows an infection with Campylobacter jejunii. Aspergilloma has not been reported to trigger MFS. In a 48-year-old male tiredness, tinnitus, otalgia, parietal hyperaesthesia, coughing, plugged nose, hypoacusis, globus sensation, epipharyngeal pain, dysarthria, hypogeusia, arthralgia, lid cloni, facial hypaesthesia and tooth ache consecutively developed. There were occasional lid cloni, left-sided facial hypaesthesia, reduced gag reflex, divesting soft palate, and absent tendon reflexes. CSF investigations revealed normal cell-count but increased protein. Antibodies against GM1 and GQ1b were negative. Atypical MFS was diagnosed. Otolaryngological examinations revealed chronic sinusitis maxillaris from an aspergilloma. After immunoglobulins and resectioning of the aspergilloma, neurological abnormalities disappeared within 19d. MFS may manifest as unilateral lower cranial nerve lesions without affection of the upper cranial nerves or ataxia. Atypical MFS may be triggered by parasinusoidal aspergilloma.

Background: Opportunistic fungal infections are rare, life-threatening conditions and are a major cause of morbidity and mortality in immunocompromised hosts. Our experience in the management of a case of combined mucormycosis and aspergillosis of the rhinocerebral region is presented., Patients and Methods: The infection developed a few weeks after tooth extraction, massively involving facial structures. After diagnosis, the patient underwent prolonged combined systemic antifungal treatment. Once the local and general conditions had stabilized, an extensive surgical debridement was performed, followed by reconstruction with a pedicled myocutaneous flap., Results: This approach was curative with patient survival after 16 months., Conclusion: Early diagnosis, early anti-fungal treatment and early stabilization of the patients' general condition are fundamental for patient survival. Surgery is necessary for fungal eradication, but must be performed according to the above conditions. Pedicled muscle flaps are considered the first reconstruction choice because of their excellent blood perfusion and resistance to fungal invasion.

A patient with an 18-year history of chronic lymphocytic leukaemia developed zygomycosis of the orbit, sinuses and nasal bones together with pulmonary fungal nodes due to Absidia corymbifera while on high dose steroids and four months after successful treatment of pulmonary aspergilloma with liposomal amphotericin B followed by oral voriconazole. He was treated successfully with extensive surgical debridement, intravenous liposomal amphotericin B and intravenous itraconazole.

We present a case of polypoid sinusitis with maxillary sinus antrolith, which is composed of Aspergillus species. Unlike most muddy or necrotic fungal balls, this first reported fungal antrolith is solid and extremely hard. Aspergillus served as a central fungal nidus associated with long-standing sinusitis, and poor sinus drainage could be a possible pathophysiology for the formation of a sinus stone. Aspergillosis infection should be considered in the differential diagnosis of a radiopaque paranasal sinus lesion. The endoscopic sinus surgery can be a reliable and minimally invasive method not only for the removal of the stone, but also for the restoration of ventilation and drainage of the diseased sinus.

A case of invasive multiple paranasal sinus aspergillosis with bony involvement is reported. A young immunocompetent lady presented with bilateral nasal obstruction due to polyps. Radiologically and histopathologically a fungal cause was kept a possibility, and the diagnosis of Aspegillus fumigatus was established by demonstration of acute angle branching septate hyphae on direct wet mount and repeated isolation in culture. Patient responded favourably to surgical excision of polyps and oral itraconazole post operatively.

A two-year-old, female spayed Australian cattle dog was diagnosed with nasal aspergillosis. The dog was treated topically with clotrimazole. Clinical signs recurred two months later and the clotrimazole treatment was repeated and 5 mg/kg itraconazole twice daily was added to it. The recommended dose of itraconazole for nasal aspergillosis is 5 mg/kg twice daily administered orally. The dog's symptoms completely resolved, but it developed an adverse febrile reaction to the Itraconazole. The Itraconazole was discontinued and the dog remained asymptomatic for four years. The dog then developed mucopurulent discharge from the right nostril and was diagnosed as having recurrent nasal aspergillosis. Itraconazole at 5 mg/kg twice daily was prescribed, which again induced a fever. When the itraconazole was decreased to 5 mg/kg once daily there were no fever episodes, but the nasal discharge was not completely resolved. The dog was then treated with topical clotrimazole Infusion, and maintained on 5 mg/kg itraconazole daily. To the authors' knowledge, this case is unique because of the delayed recurrence of nasal aspergillosis. Additionally, the idiosyncratic febrile reaction to the itraconazole has not previously been reported in the veterinary literature, but is similar to reports of drug-induced fever in humans.

Aspergilloma of the maxillary sinus is a non-invasive mycotic infection of the immunocompetent host. Nowadays its treatment remains surgical removal, and endoscopic endonasal middle meatus antrostomy is retained as the most popular approach. In our experience, a complementary endoscopic canine fossa approach is often needed to achieve a complete resection of the fungus ball. This fact led us to ask ourselves if an isolated endoscopic canine fossa approach had any advantages over the endonasal middle meatus antrostomy. In this paper we retrospectively analyse the results of the surgical treatment of 31 patients presenting maxillary sinus aspergillomas. These patients were all operated between January 1997 and January 2003 in our Otolaryngology Department. They were divided in three groups. Group A included 10 patients operated through an endonasal middle meatotomy only, group B included 9 patients who were operated through a combined approach (endonasal middle meatus antrostomy and endoscopic canine fossa approach), and group C included 12 patients who were operated through an endoscopic canine fossa approach alone. No recurrences were noted in any group, but in group B three patients presented mild complications like persistent purulent discharge through the meatotomy and nasal crusting. The endoscopic canine fossa approach offers several advantages over other techniques. These include an optimal visualization of all maxillary sinus walls and recesses, the possibility of performing the procedure under local anaesthesia and on an outpatient basis, the preservation of the anatomy and physiology of the natural maxillary ostium and an easy removal of the eventual foreign bodies of dental origin in the sinusal cavity that could favourite the development of an aspergilloma.

Objective: To study the pathogens of fungus balls in paranasal sinuses and establish an immunohistochemical test by which the main opportunistic fungi could be identified., Methods: Twenty-five patients with fungal balls were treated by surgical removal of the fungus ball in the infected sinuses. The pathogenic fungi on the specimens were identified by means of routine PAS and immunohistochemical staining methods, and the sensitivity of the two methods were compared., Results: The most commonly infected sinus was the maxillary sinus, followed by sphenoid sinus. Pathogens of fungal balls were found to be aspergillus (92%, 23/25) and candida 2 cases (8%). Aspergillus and candida albicans in infected sinuses could be specifically identified by immunostainning. There was no statistically significant differences of sensitivity between immunostainning and PAS stain., Conclusions: The main pathogen of the fungus ball was aspergillus. Immunostainning was a rapid and reliable method to identify fungi in infected tissues of paranasal sinuses. It should be widely used in the diagnosis of fungal sinusitis.

A prospective study was conducted in 25 consecutive patients of paranasal sinus aspergillosis to categorize and treat them based on a fixed treatment protocol. The three types of aspergillosis categorized as per definitive criteria were chronic invasive (six), non-invasive (fungus ball) (seven) and non-invasive destructive (12). Adjuvant chemotherapy was employed in non-invasive destructive and chronic invasive disease. Ketoconazole was used in the first variety and itroconazole in the latter. Only two patients had recurrence after a mean follow-up of 11 months (range: 6-20 months). They belonged to the non-invasive destructive category and the recurrence had progressed to invasive variety. It is suggested that non-invasive destructive disease should be followed up regularly with endoscopic examination, CT and fungal serology to detect recurrence. Categorization of the paranasal sinus aspergillosis helps to institute proper treatment. Adjuvant chemotherapy in the form of ketoconazole along with surgery is effective in non-invasive destructive disease to prevent recurrence and progression to invasive disease. Chronic invasive disease with its propensity to involve orbit and intracranial cavity should be managed at the earliest with surgery and itraconazole.

A retrospective study of 40 otherwise healthy children suffering from paranasal aspergillosis is presented. Fifteen percentage of this group was under 10 years of age. The clinical characteristics were marked facial deformity, orbital involvement (52.5%) and skull base erosion (12.5%). Ethmoid sinus was the commonest sinus to be affected. Aspergillus serology was positive in 35% and fungal culture grew the organism in 40%. Histopathology revealed allergic or non-invasive fungal infections without any tissue invasions. Surgery was performed in all except one case. Recurrence was 15% treated by revision surgery and antifungal therapy.

Objective: To assess paranasal sinus material histopathologically for the presence of fungus., Material and Methods: Paraffin-embedded archival biopsy samples of patients who underwent endonasal sinus surgery between 1992 and 2002 were retrospectively assessed for the presence of fungi. Hematoxylin-eosin-stained sections of the materials were re-evaluated, and Gomori's methanamine silver stain was also applied as required., Results: Fungus (Aspergillus) was detected histopathologically in only 21476 patients, both of whom were immunocompetent. One patient was considered to have chronic indolent sinusitis and the other allergic fungal sinusitis., Conclusions: Although histopathologic assessment is one of the most important diagnostic tools, on its own it may lead to underestimation of fungal involvement of the paranasal sinuses. Alternatively, fungal involvement of the paranasal sinuses may be very infrequent in Turkey.

Aspergillus is a ubiquitous mold that can cause several types of symptomatic infections: allergic aspergillosis, typically in young atopic patients; aspergillomas (often referred to as fungus balls); and invasive aspergillosis, typically seen in debilitated or immunocompromised patients. We describe an 85-year-old woman who was not immunocompromised but had invasive aspergillosis of the paranasal sinus that resulted in unilateral headache and retrobulbar optic neuropathy. After extensive differential diagnostic examination, we concluded that the condition was possibly related to the long-term use of nasal corticosteroids (fluticasone propionate aqueous nasal spray). Surgical removal of solid masses of Aspergillus organisms followed by extended treatment with antifungal agents resulted in a favorable outcome.