Fungus ball of the paranasal sinuses: Report of two cases and literature review

Abstract

Summary Introduction: Fungal ball of the sinuses is a not invasive infection that if characterizes for its chronicity, being the majority related with previous endodontic treatment. Affect mainly the breasts to maxillary; even so all the breasts can be involved. The main etiological agent is the Aspergillus spp. The computed tomography, had to characteristic the radiological presentations, suggests the diagnosis that is carried through definitively through histopathological analyses. The treatment standard-gold is the sinus surgery with average meatal antrostomy. Objective: Reporting two cases of fungal ball of the sinuses and to stand out important aspects of this pathology. Story of the Cases: Case 1) Patient of the feminine sex, 78 years old, presented itself with complaints of face pain has 6 months and previous history of endodontic treatment. To the physical examination it was evidenced purulent secretion presence in left average meatus. Ray X presented complete veiling of the breasts to maxillary left, while the computed tomography showed injury calcified in this place. Sinusotomy was become fulfilled that evolved well. Case 2) Patient of the feminine sex, 70 years old, looked attendance for history of sinusitis of repetition. To the physical examination no particularity was not perceived. The computed tomography, as well as the magnetic resonance, detected thickening of the mucous wall of the breasts to maxillary left, beyond a calcified mass. It was become fulfilled same sequence of treatment and the patient also evolved well. Final Considerations: The fungal infection must be considered in the patients who if present with chronic sinusitis, that they do not answer to the antibiotic use and that they possess history of endodontic manipulation.

Literature review. Noninvasive fungal rhinosinusitis

“…FB commonly appears in normal immunocompetent persons, at 60-70 years of age, although, in some retrospective studies, age ranged within 14-87 years. There is a considerable and constant predilection for females of about 57-64%, with a ratio of 1.5-1.9:1 between men and women 4, 9,10 . Usually, the disorder is unilateral, involving only one sinus (up to 90-99% of the cases).…”

“…The Mucorales species are on the second place. Other fungal species are even more rarely detected: Cephalosporium, Candida albicans, Scedosporium apiospermum, Cladosporium 3,6,9,11 . The FB sinus pathophysiology remains unknown.…”

“…According to the airborne theory, large quantities of fungal spores in the air penetrate the sinuses through the natural ostia, multiply and become pathogenic when the sinus becomes an anaerobic environment. A possible cause may be the ostiomeatal obstruction, accentuated by anatomical factors (septum deviation, turbinate hypertrophy) contributing to the stasis occurred inside the sinuses, with the development of a hypoxic and anaerobic environment, with the lowering of the pH -a favourable and ideal condition for the proliferation of fungi and increasing the possibility of allergic reactions 9,12,13 . The odontogenic path is a iatrogenic one, where fungal colonization of the maxillary sinus occurs through a iatrogenic oro-antral communication, secondary to dental extraction, by periodontal lesions, channel perforation or, most frequently, after endodontic treatment with overfilling of the dental channel.…”

“…Multi-sinus localization was found only in 6-41% of the cases, the impairment of two sinuses being described in 3.3-10.3% of the cases, and of three sinuses in 5.8-17.2% 3,[6][7][8]11 . According to recent studies, FB represents 3.7% of all cases of inflammatory chronic rhinosinusitis (CRS) requiring surgery 9 . The pathogen most commonly implicated (in European countries) is Aspergillus (in 90-96% of the cases), especially Aspergillus fumigatus, rarely Aspergillus flavus, Aspergillus niger and Aspergillus nidulans.…”

“…The FB sinus pathophysiology remains unknown. The disorder develops in two conditions: penetration of hyphae and fungal spores into a paranasal sinus and creating the environment that contribute to the growth of fungi 9,12,13 . Three possible theories of FB development have been suggested: airborne, odontogenic and mixed.…”