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A case of the inferior meatus fungus ball
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British Journal of Oral and Maxillofacial Surgery 46 (2008) 681–682
Short communication
A case of the inferior meatus fungus ball Gyu Ho Lee, Hoon Shik Yang, Kyung Soo Kim ∗ Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Chung-Ang University Hospital, 224-1, Heukseok-dong, Dongjak-gu, Seoul, Korea Accepted 10 March 2008 Available online 8 May 2008
Abstract A fungus ball is usually found in just one sinus, often the maxillary sinus, followed by the sphenoid, ethmoid, and frontal sinuses. We report the case of a fungus ball in the inferior meatus of a 50-year-old woman, which was successfully removed by nasal endoscopic surgery. This is the first case to our knowledge that has been reported at this unusual site. In addition, we hypothesise that “inferior meatus fungus ball” is a disease entity similar to a sinus fungus ball. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Inferior meatus; Fungus ball
Case report A 50-year old woman developed foul-smelling rhinorrhoea in the right nasal cavity over 10 months. Seventeen years previously she had had a dental procedure that involved the extraction of the third molar from the right maxilla and drainage of pus from the site of extraction. On examination, the nasal septum was deviated to the left, the inferior turbinate of the right nasal cavity was hypertrophied, and there was purulent discharge at the nasal floor. Unilateral right chronic maxillary sinusitis was suspected and a simple radiograph and computed tomogram (CT) of the postnasal space were obtained. The radiograph showed hypoplasia of the right maxillary sinus and partial haziness. The CT (Figs. 1 and 2) showed calcifications and soft tissue density in the right inferior meatus. The right maxillary sinus was contracted and showed partial bony erosion. The right inferior meatus was examined closely with a 30o endoscope, and a black-brownish fungal ball and granulation tissue were found on the lateral nasal wall. ∗ Corresponding author. Chung-Ang University Hospital College of Medicine Department of Otorhinolaryngology-Head and Neck Surgery 2241, Heukseok-dong, Dongjak-gu, Seoul Republic of Korea. Tel.: +82 2 6299 1765; fax: +82 2 825 1765. E-mail address: [email protected] (K.S. Kim).
The patient was operated on endoscopically and the right inferior turbinate fractured medially to obtain good exposure. The fungus ball in the inferior meatus and granulation tissue on the lateral nasal wall were removed completely. After removal of the uncinate process and widening of the antrostomy endoscopically, the maxillary sinus was explored with a 30o endoscope. A little pus was found in the maxillary sinus, but there was no fungal material, and no route between the maxillary sinus and the inferior meatus. Microscopic findings (PAS stain) of the fungus ball showed that the hyphae of the fungus was septated and smooth-surfaced, with dichotomous branching (Fig. 3), but there was no mucosal invasion of fungal hyphae or nonspecific chronic inflammation on hematoxylin and eosin stain. The pathological diagnosis was therefore fungus ball, and the patient has done well during a follow-up period of 6 months with no signs of recurrence.
Discussion Recently clinicopathological criteria for the diagnosis of a paranasal fungus ball have been proposed by de Shazo:1 radiological evidence of sinus opacification with or without calcifications; mucopurulent cheesy or clay-like material
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.03.007
682
G.H. Lee et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 681–682
Fig. 1. The axial view of a computed tomogram of the paranasal sinuses showing calcification and soft tissue density in the right inferior meatus (Black Arrow). The right maxillary sinus is contracted and shows that there is partial erosion of the bone.
Fig. 2. The coronal view of a computed tomogram of the paranasal sinuses showing calcification and soft tissue density in the right inferior meatus (Thick Black Arrow). The medial wall of the right maxillary sinus is displaced superiorly and laterally (Thin Black Arrow), and there is partial erosion of the right inferior turbinate and maxillary sinus.
within the sinus; dense conglomeration of hyphae (= fungal ball) separate from the sinus mucosa; non-specific chronic inflammation of the mucosa; no predominance of eosinophils, granuloma, or allergic mucin; and no histological evidence of fungal invasion of mucosa, blood vessels, or bone seen microscopically after special stains for fungi. We propose the diagnosis of “fungus ball of the inferior meatus” according to these criteria because the fungus ball was found within the inferior meatus. In previous reports, it has been suggested that fungus balls may develop in any poorly ventilated sinus in the
Fig. 3. Periodic acid-Schiff stain showing abundant fungal hyphae. The hyphae are uniform, septated and branched dichotomously (original magnification ×400).
long term, and they develop through a iatrogenic oroantral communication.2,3 Previous endodontic treatment is also a strong risk factor for the fungus ball.4 However, Tsai et al5 have provided statistical data to support the principle that the maxillary fungus ball is not associated with obstruction of the osteomeatal complex and that another as-yet-unexplained mechanism must be responsible. In our case, the pathogenesis was not clear, but predisposing local factors are a contracted maxillary sinus and widened inferior meatus. In other words, because the maxillary-sinuslike inferior meatus was poorly ventilated, hypoventilation of the meatus seemed to have an important role in trapping fungal spores and providing anaerobic conditions for the development of the fungus ball.
References 1. deShazo RD. Fungal sinusitis. Am J Med Sci 1998;316:39–45. 2. Grosjean P, Weber R. Fungus balls of the paranasal sinuses: a review. Eur Arch Otorhinolaryngol 2007;264:461–70. 3. Barry B, Topeza M, Gehanno P. Rˆole de l’environnement dans la survenue d’une aspergillose naso-sinusienne (Aspergillosis of the paranasal sinus and environmental factors). Ann Otolaryngol Chir Cervicofac 2002;119:170–3. 4. Mensi M, Piccioni M, Marsili F, et al. Risk of maxillary fungus ball in patients with endodontic treatment on maxillary teeth: a casecontrol study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:433–6. 5. Tsai TL, Guo YC, Ho CY, et al. The Role of ostiomeatal complex obstruction in maxillary fungus ball. Otolaryngol Head Neck Surg 2006;134:494–8.
British Journal of Oral and Maxillofacial Surgery 46 (2008) 681–682
Short communication
A case of the inferior meatus fungus ball Gyu Ho Lee, Hoon Shik Yang, Kyung Soo Kim ∗ Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Chung-Ang University Hospital, 224-1, Heukseok-dong, Dongjak-gu, Seoul, Korea Accepted 10 March 2008 Available online 8 May 2008
Abstract A fungus ball is usually found in just one sinus, often the maxillary sinus, followed by the sphenoid, ethmoid, and frontal sinuses. We report the case of a fungus ball in the inferior meatus of a 50-year-old woman, which was successfully removed by nasal endoscopic surgery. This is the first case to our knowledge that has been reported at this unusual site. In addition, we hypothesise that “inferior meatus fungus ball” is a disease entity similar to a sinus fungus ball. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Inferior meatus; Fungus ball
Case report A 50-year old woman developed foul-smelling rhinorrhoea in the right nasal cavity over 10 months. Seventeen years previously she had had a dental procedure that involved the extraction of the third molar from the right maxilla and drainage of pus from the site of extraction. On examination, the nasal septum was deviated to the left, the inferior turbinate of the right nasal cavity was hypertrophied, and there was purulent discharge at the nasal floor. Unilateral right chronic maxillary sinusitis was suspected and a simple radiograph and computed tomogram (CT) of the postnasal space were obtained. The radiograph showed hypoplasia of the right maxillary sinus and partial haziness. The CT (Figs. 1 and 2) showed calcifications and soft tissue density in the right inferior meatus. The right maxillary sinus was contracted and showed partial bony erosion. The right inferior meatus was examined closely with a 30o endoscope, and a black-brownish fungal ball and granulation tissue were found on the lateral nasal wall. ∗ Corresponding author. Chung-Ang University Hospital College of Medicine Department of Otorhinolaryngology-Head and Neck Surgery 2241, Heukseok-dong, Dongjak-gu, Seoul Republic of Korea. Tel.: +82 2 6299 1765; fax: +82 2 825 1765. E-mail address: [email protected] (K.S. Kim).
The patient was operated on endoscopically and the right inferior turbinate fractured medially to obtain good exposure. The fungus ball in the inferior meatus and granulation tissue on the lateral nasal wall were removed completely. After removal of the uncinate process and widening of the antrostomy endoscopically, the maxillary sinus was explored with a 30o endoscope. A little pus was found in the maxillary sinus, but there was no fungal material, and no route between the maxillary sinus and the inferior meatus. Microscopic findings (PAS stain) of the fungus ball showed that the hyphae of the fungus was septated and smooth-surfaced, with dichotomous branching (Fig. 3), but there was no mucosal invasion of fungal hyphae or nonspecific chronic inflammation on hematoxylin and eosin stain. The pathological diagnosis was therefore fungus ball, and the patient has done well during a follow-up period of 6 months with no signs of recurrence.
Discussion Recently clinicopathological criteria for the diagnosis of a paranasal fungus ball have been proposed by de Shazo:1 radiological evidence of sinus opacification with or without calcifications; mucopurulent cheesy or clay-like material
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.03.007
682
G.H. Lee et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 681–682
Fig. 1. The axial view of a computed tomogram of the paranasal sinuses showing calcification and soft tissue density in the right inferior meatus (Black Arrow). The right maxillary sinus is contracted and shows that there is partial erosion of the bone.
Fig. 2. The coronal view of a computed tomogram of the paranasal sinuses showing calcification and soft tissue density in the right inferior meatus (Thick Black Arrow). The medial wall of the right maxillary sinus is displaced superiorly and laterally (Thin Black Arrow), and there is partial erosion of the right inferior turbinate and maxillary sinus.
within the sinus; dense conglomeration of hyphae (= fungal ball) separate from the sinus mucosa; non-specific chronic inflammation of the mucosa; no predominance of eosinophils, granuloma, or allergic mucin; and no histological evidence of fungal invasion of mucosa, blood vessels, or bone seen microscopically after special stains for fungi. We propose the diagnosis of “fungus ball of the inferior meatus” according to these criteria because the fungus ball was found within the inferior meatus. In previous reports, it has been suggested that fungus balls may develop in any poorly ventilated sinus in the
Fig. 3. Periodic acid-Schiff stain showing abundant fungal hyphae. The hyphae are uniform, septated and branched dichotomously (original magnification ×400).
long term, and they develop through a iatrogenic oroantral communication.2,3 Previous endodontic treatment is also a strong risk factor for the fungus ball.4 However, Tsai et al5 have provided statistical data to support the principle that the maxillary fungus ball is not associated with obstruction of the osteomeatal complex and that another as-yet-unexplained mechanism must be responsible. In our case, the pathogenesis was not clear, but predisposing local factors are a contracted maxillary sinus and widened inferior meatus. In other words, because the maxillary-sinuslike inferior meatus was poorly ventilated, hypoventilation of the meatus seemed to have an important role in trapping fungal spores and providing anaerobic conditions for the development of the fungus ball.
References 1. deShazo RD. Fungal sinusitis. Am J Med Sci 1998;316:39–45. 2. Grosjean P, Weber R. Fungus balls of the paranasal sinuses: a review. Eur Arch Otorhinolaryngol 2007;264:461–70. 3. Barry B, Topeza M, Gehanno P. Rˆole de l’environnement dans la survenue d’une aspergillose naso-sinusienne (Aspergillosis of the paranasal sinus and environmental factors). Ann Otolaryngol Chir Cervicofac 2002;119:170–3. 4. Mensi M, Piccioni M, Marsili F, et al. Risk of maxillary fungus ball in patients with endodontic treatment on maxillary teeth: a casecontrol study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:433–6. 5. Tsai TL, Guo YC, Ho CY, et al. The Role of ostiomeatal complex obstruction in maxillary fungus ball. Otolaryngol Head Neck Surg 2006;134:494–8.