Whilst the Aspergillus Website & the Fungal Research Trust have taken every precaution in compiling this site, neither it nor any contributors or charity Trustees can be held responsible for using the information held herein. Medical information changes constantly and the information presented here should not be considered complete or exhaustive and should not be relied upon as the sole or primary source on which to base diagnosis or treatment for any individual.

This site is not designed to and does not provide medical advice, professional diagnosis, opinion, treatment or services to you or to any other individual. Through this site and links to other sites, the Aspergillus Website provides general information for educational purposes only. The information provided in this site, or through links to other sites, is not a substitute for medical or professional care, and you should not use the information in place of a visit, call, consultation or the advice of your physician or other healthcare provider.

Neither The Aspergillus Website nor the FRT is liable or responsible for any advice, course of treatment, diagnosis or any other information, services or product you obtain through this site.

I have read this, proceed to the article

Aspergillus fungal ball of sinuses (Saprophytic sinus aspergillosis)

Images

Paranasal saprophytic aspergillosis is an uncommon cause of chronic or recurrent sinusitis. One series showed that 5% of 414 children treated for sinusitis had fungi only isolated and another 24% had bacteria and fungi isolated together (Laskownicka et al, 1978). In 600 adults treated for maxillary sinusitis, 14% revealed fungi, mostly A.fumigatus (Grigoriu et al, 1979). However most ear, nose and throat surgeons identify cases at surgery only every few years. The criteria for operation vary substantially and most patients with chronic sinusitis are not operated on. Most cases are in young to middle-aged adults.

It is likely that anatomical variation accounts for some cases (Stammberger, 1985). A common clinical finding is a bent middle turbinate with its convexity facing laterally instead of medially. Distortion of the osteomeatal complex, e.g. anatomical variation of the uncinate process will interfere with maxillary and frontal sinus drainage. Recurrent bacterial sinusitis leads to swelling of the ethmoidal air cells, further occluding the maxillary ostium. It is the combination of these factors that leads to most cases of paranasal saprophytic aspergillosis. In addition certain dental produces on the upper premolars and molars may introduce zinc oxide into the maxillary sinus which in turn creates favourable conditions for the growth of Aspergillus.

Usually discovered accidentally at surgery, prior symptoms are typical of chronic sinusitis; nasal congestion, facial discomfort or mild anterior headache, or post nasal dip. Most patients have previously received multiple courses of antibiotics, usually with at least a partial clinical response. Radiographs of the sinus demonstrate complete opacification of, usually, the maxillary sinus but occasionally of the sphenoid or rarely the frontal sinus. Usually only one sinus is involved radiologically and no bone erosion or extension of the soft tissue mass into adjacent structures. Endoscopic or CT examination of the nose usually demonstrates however, ethmoid involvement in addition to maxillary and/or sphenoid involvement (Stammberger, 1985).

Surgical aeration of the sinuses almost always cures the problem. Typically this is done via a Caldwell-Luc procedure and the sinus if found to contain a cheese-like, rubbery or friable soft tissue mass. The colour varies from green, brown to black and may be malodorous. The underlying mucosa is usually oedematous and may contain polyps. Most surgeons remove the mucosa and create a large antrostomy into the nose. Surgeons with extensive experience of the disease also maintain that the ipsilateral ethmoids should be explored and drained either endoscopically or surgically via a nasal approach (Stammberger, 1985). Relapse may occur otherwise. The role of nasal packing with amphotericin B or another antifungal agent is not established.

David W. Denning FRCP FRCPath FIDSA FMedSci
Professor of Medicine and Medical Mycology
Director, National Aspergillosis Centre
Education and Research Centre
University Hospital of South Manchester (Wythenshawe Hospital)
Southmoor Road
Manchester M23 9LT UK

June 1998