Diagnosis of Primary Invasive Oral Aspergillosis

1539

LETTERS TO THE EDITOR SSRO can affect patients’ daily lives. With CT examination, we can more precisely predict the occurrence of ND of the IFAN after SSRO than without CT, and this better serves our patients. We therefore advocate the use of CT examinations before performing SSRO.

In conclusion, although the subject of the report is interesting and important, confirmatory diagnosis of primary invasive oral aspergillosis is not clear in the case presented. YOSHINARI MYOKEN, DDS, PHD YOSHINORI FUJITA, DDS, PHD TATSUMI SUGATA, DDS, PHD Hiroshima, Japan

YASUHIRO MORIMOTO, DDS, PHD IZUMI YOSHIOKA, DDS, PHD Fukuoka, Japan

References 1. Yoshioka I, Tanaka T, Khanal A, et al: Relationship between inferior alveolar nerve canal positions at the mandibular second molar in patients with prognathism and the possible occurrence of neurosensory disturbance after sagittal split ramus osteotomy. J Oral Maxillofac Surg 68:3022, 2010 2. Bagheri SC, Meyer RA, Khan HA, et al: Microsurgical repair of the peripheral trigeminal nerve after mandibular sagittal split ramus osteotomy. J Oral Maxillofac Surg 68:2770, 2010 3. Yoshioka I, Tanaka T, Khanal A, et al: Correlation of mandibular bone quality with neurosensory disturbance after sagittal split ramus osteotomy [Epub ahead of print Nov 9]. Br J Oral Maxillofac Surg 2010 4. Yoshida T, Nagamine T, Kobayashi T, et al: Impairment of the inferior alveolar nerve after sagittal split osteotomy. J Craniomaxillofac Surg 17:271, 1989 5. Yamamoto R, Nakamura A, Ohno K, et al: Relationship of the mandibular canal to the lateral cortex of the mandibular ramus as a factor in the development of neurosensory disturbance after bilateral sagittal split osteotomy. J Oral Maxillofac Surg 60:490, 2002 6. Nishioka GJ, Zysste MK, van Sickels JE: Neurosensory disturbance with rigid fixation of the bilateral sagittal split osteotomy. J Oral Maxillofac Surg 45:20, 1987

doi:10.1016/j.joms.2011.02.002

DIAGNOSIS OF PRIMARY INVASIVE ORAL ASPERGILLOSIS To the Editor:—With interest, we read the article of Fuqua et al1 regarding primary invasive oral aspergillosis. Because of its rarity among the oral diseases, a well-described study can provide valuable clinical information. In this article, however, some serious diagnostic inaccuracies are present that could make the conclusions unclear. The main shortcomings are as follows. First, the disease was diagnosed as primary invasive oral aspergillosis by the palatal lesion, which was far from the marginal gingiva. Primary invasive oral aspergillosis, however, usually occurs in the marginal gingiva and extends to the attached gingival and adjacent mucosa involving the alveolar bone.2 Furthermore, computed tomography scans apparently demonstrated the opacification of the maxillary and ethmoid sinus, indicating sinusitis. Therefore, these clinicoradiological findings are strongly suggestive of invasive maxillary sinus aspergillosis invading the palatal mucosa as reported by Napoli et al.3 Second, several filamentous fungi such as Fusarium and Trichoderma are indistinguishable from Aspergillus by the usual histopathological examination, and even cases of Zygomycosis have occasionally been incorrectly identified as Aspergillus species.4 To confirm Aspergillus infection, the authors should show the evidence of Aspergillus species by fungal culture of the tissue samples or other methods, including serum Aspergillus galactomannan antigen and in situ hybridization.4

References 1. Fuqua TH Jr, Sittitavornwong S, Knoll M, et al: Primary invasive oral aspergillosis: An updated literature review. J Oral Maxillofac Surg 68:2557, 2010 2. Myoken Y, Sugata T, Kyo T, et al: Pathological features of invasive oral aspergillosis. J Oral Maxillofac Surg 54:263, 1996 3. Napoli JA, Donegan JO: Aspergillosis and necrosis of the maxilla: A case report. J Oral Maxillofac Surg 49:532, 1991 4. Myoken Y, Sugata T, Mikami Y, et al: Identification of Aspergillus species in oral tissue samples of patients with hematologic malignancies by in situ hybridization: A preliminary report. J Oral Maxillofac Surg 66:1905, 2008

doi:10.1016/j.joms.2011.01.045

PRIMARY INVASIVE ORAL ASPERGILLOSIS To the Editor:—We reviewed with interest the letter to the editor regarding our article, “Primary Invasive Oral Aspergillosis: An Updated Literature Review.” We firmly believe that our report represented a solid documentation of primary invasive aspergillosis of the palate rather than a primary sinus infection with secondary oral involvement, as suggested by Myoken et al from Japan. Before making the diagnosis, we extensively review all available data on the patient, including computerized tomography (CT) images and all available previous medical history. Although the patient in our case has suffered from chronic sinusitis for many years, before his diagnosis of leukemia, he did not exhibit any episodes of epistaxis, nasal discharge, and pain. The CT images of the thorax were noncontributory. Similarly, examination of the nose and paranasal sinus images did not demonstrate any evidence of calcification, resorption, or extensive destruction of the sinonasal bones, palate, or floor of the maxillary sinus, which would be expected in aspergillus sinusitis occurring in a background of a disseminated fungal infection or a palatal infection, occurring secondary to a descending sinus disease.1-3 Although ideally, fungal cultures are performed and may further confirm the diagnosis of invasive aspergillosis and exclude other filamentous fungi, including Fusarium and Trichoderma, the diagnosis of invasive aspergillosis can still be confidently made in the absence of microbiological confirmation.4 Histomorphological examination is considered to be among the golden-standard methods used in the diagnosis of aspergillosis.5 Blood cultures and serological testing may not be always reliable in establishing the diagnosis,6 and cultures may be negative even in the presence of the typical histological feature of Aspergillus.7 Furthermore, several cases of primary invasive aspergillosis of the maxillofacial region were confidently diagnosed on the basis of histomorphological examination, similar to our case.8 Interestingly, false-positive test results for Aspergillus galactomannan (which can further help to establish the diagnosis) may occur secondary to the use of antibiotics,9 which theoretically could have altered the interpretation in the