j. Cranio-Max.-Fac.Surg.
18 (I990) 33
J.Cranio-Max.-Fac. Surg. 18 (1990) 33-40
9 GeorgThiemeVerlagStuttgart 9 New York
Sinus Aspergillosis
Christophe De Foer*, Eric Fossion*, Jean-Marie Vaillant**
*Dept. ofOra/and Head and NeckSurgery
(Head: Prof. E. Fossion,M.D., D.M.D.),
UniversityHospital Leuven,Belgium
**Institute for Stomatologyand Maxillo-FacialSurgery
(Director: Prof. J. M. Vaillant.M.D., D.M.D.)
UniversityHospital "Piti6-Salp&ri~re"Paris, France
Submitted 22.12.88; accepted 4.4.89
Introduction
Aspergillus is an ubiquitous mould which produces
sporulating structures. Inhalation of the spores of any of
the possibly pathogenic species (A. Flavus, A. Niger, and
most frequently A. Fumigatus) must be extremely com-
mon. However, unless there is massive inhalation, or an
immunosupressed host, disease is rare. Pulmonary Asper-
gillosis and Aspergillic otomycosis are relatively common,
but Sinus Aspergillosis (S. A.) is an uncommon disease. It
presents in two forms; a ball of hyphae, may form in a
chronically obstructed sinus (non-invasive S.A), but, much
less commonly, it may spread slowly to the orbit and brain
(invasive S.A).
Terminology and Classification
S. A. was first describes some hundred years ago. At first it
w a s often regarded as a site of syphillis, a very common
disease in those days. In 1906 the Frenchman Texier (cited
by Legent et al. 1982) was the first to exclude the syphilli-
tic origin, to mention tile possible dental origin and to re-
cognise a "pseudo-tumoral" form of S. A. Fifty years later,
Andersen (Andersen and Steserup, 1956) emphasized the
importance of Texier's remark that systematic bacteriolog-
ical investigation would probably show an unexpectedly
high number of S.A's. In 1965, Hora (1965) published a
classification (similar to that of Texier) based on a series of
25 patients in Texas (Table 1).
Nowadays, most authors refer to Hora's work as tile basic
classification of S. A. We shall do the same in this article;
even though Texier's terminology seems more logical to us
than that of his American colleague, sixty years later. Te-
xier used a more adequate terminology, since terins such
as "light forms" vs. "pseudo-tumoral forms" describe
more accurately the radiological images one is confronted
with in the clinical situation. The Franco-Anglophone lan-
guage barrier has had other consequences than polemics
on terminolgy. S.A. is a relatively rare disease, and since
most authors refer to ideas of fellow countrymen w h o
presented (larger) series in the past, different philosophies
have emerged on either side of the barrier. No historical
review of the disease has ever been complete, because of
lan.guage problems (Stammberger et al., 1984, Robb 1986).
lt-'(vas not our goal to make an exact quantification of
S:A. cases in the literature, kVea'nerely wanted to compare
those different ideas on aetiopathogenesis and check them
against our series.
Summary
The prevalence of Aspergillus sinusitis is often under-
estimated because the vast majority of cases are classi-
fied as "unspecified sinusitis". Two possible aetio-pa-
thogenic mechanisms can be involved in the develop-
ment of this fungal infection. Traditionally, the litera-
ture emphasised the "anglophone" hypothesis which is
based on the inhalation of spores. More recently, the
"french" model, based on oro-sinusal fistula and/or
the perforation of the maxillary sinus by root canal-
filling material, is believed to explain the majority of
cases in our industrialised environments. Still, neither
model explains the totality of cases and several remain
beyond comprehension. The disease most commonly
presents as a chronic bacterial sinusitis. The process
can however become invasive, thus resembling malig-
nancy, with eventually a fatal outcome. Doctors and
dentists should know the possible danger, presented by
zinc-oxide-eugenol-paste in the sinus. Radical surgery
is the treatment of choice, since a prolonged conserva-
tive approach (antibiotics, corticosteroids) can only
worsen tile prognosis. This paper discusses different
aspects of the disease, and presents 10 cases, observed
at the University Hospitals of Paris (France) and Leu-
ven (Belgium).
Key words
Sinusitis - Aspergillus - Mycotic Infections - Asper-
gillosis
Aetiopathogenic Theories
Legent et al. (1980) presented a pathogenic mechanism in
the French literature, which is hardly ever mentioned in
the Anglo-American reports. This mechanism is based on
the initial colonisation of the maxillary sinus through a (ia-
trogenic) bucco-sinusal connection (e.g. post-extraction
site, periodontal destruction, root canal perforation).
This "dental" model should give an alternative for the (in
the Anglosaxon literature) widespread concept of spore-in-
halation as the one possible explanation for sinus colonisa-
tion (Vaillant et al., 1983; Braun et al., 1987; Ragot et al.,
1988).
It is true that the "aerogenic" model can explain tile ma-
jority of cases in all today's larger series. One should how-
ever keep in mind that most of these reports on S.A.'s are
observed-in entirely different atmospherical conditions
e.g. tile Sudan (Milose[ and Mahgoub, 1969; Mahgoub,
1971; Veress et al., 1973), Saudi-Arabia (Bassiouny et al.,
1982) or in India (Bahadur et al., 1983), than the ones we
are confronted with in \Vestern-Europe. Traditionally
S.A. is observed*in subtropical countries, with a warm,
moist climate, where tile high Asp. spore-count in the dust
("sand-storm's" cfr. Milosef and Mahgoub, 1969) contri-
butes considerably to the inoculation of the sinus via nose-
inhalation. Moreover, the subtype of Aspergillus found in
patients, recruited in those environements, seems to be
more virulent than the subtype cultured from specimens
from patients living in our \Vestern-European urban con-
ditions.
34 ]. Cranio-Max.-Fac. Surg. 18 (1990)
Fig.1 Arrows on this Panoramic radiograph show a foreign body
in the left maxillary sinus. It can be a eugenate fragment, floating in
the sinus after perforation of the sinus mucosa during root canal
treatment on 26 (case 7 - see also Fig.2).
Fig.3 Tomographic radiograph indicating destruction of medial
,maxillary sinus wall with orbital involvement (case 8).
In Europe however, one must consider tile higher stand-
ards of hygiene and the fact that people request medical
care at a relatively early stage. Thus we are seldom con-
fronted with the late, spectacular forms of S.A. (with the
typical "mastic-like" Aspergilloma) that are seen in the Su-
dan, India etc. Most S.A.'s in our countries are therefore
regarded as banal, bacterial sinusitis and treated as such at
an early stage. Systematic investigation of the cnretted ma-
terial is seldom performed. Routine pathology screening
would probably reveal a much higher incidence of S.A:
than is generally thought (Legent et al., 1982). In a recent
American study by Zinreich et al. (1988), routine patholo-
gy screening revealed 25"fungal sinusitises out of a total
number of 293 patients operated on for chronic sinu-
sitis.
Christophe De Foer et al.
Fig.2 CT-scan image showing the destruction of the medial wall
of the maxillary sinus and invasion of the ethmoid sinus. There is a
metal-dense body in the sinus (case 7 - see also Fig. 1).
Table I Primary Aspergillosis of the paranasal sinuses and asso-
ciated areas (J. F. Hora, Houston, Texas, 1965)
Non-invasive majority of cases
Aspergillosis symptoms of banal chronic sinusitis
increased resistance to usual therapy
x-rays show antrum-opacification, no bone
destruction
irrigation of antrum yields dark, greasy
material, from which different
Asp. species can be cultured
good prognosis after surgery
Invasive rarely seen
Aspergillosis: serious clinical picture
Pain plus slowly growing mass, mimicking a
malignancy
bone destruction on x-ray
Today, only some 400 case-reports of S. A. have been pub-
lished in the world-literature. In Western-Europe most au-
thors report on one or two isolated cases.
Material and Methods
We have reviewed the patient material between 1976 and
1987 in two maxillo-facial centres; tile Institute for Stom-
atology and Maxillo-Facial Surgery in Paris (France) - (see
case~ 1 to 5) and the Department of Oral and Head and
Neck Surgery in Leuven (Belgium)- (see cases 6 to 10). At-
tention has been paid to the clinical and radiological pres-
entation of the disease, to the anamnestic factors, to tile
peroperativejindings, and to histopathological and bacter-
iological examination of the collected material, in order to
compare these details with the above-mentioned classifica-
tion of Hora (1965) and to both aetiopathogenic theories.
Case Reports
Case 1: 31-year-old caucasian woman, dental implant in
location 25, extending into the left maxillary sinus. Im-
plant removed after 6 months and patient kept on anti-
biotics and non-steroidal auti-inflammatory medication,
Sinus Aspergillosis
fistula closed spontaneously. On admission, left maxillary
sinus painful, diminished radiolucency but absence of bone
destruction. Caldwell-Luc sinus debridement performed
and pathological confirmation of diagnosis of Aspergillo-
ma on mastic-like material. N o relapse in 9 years.
Ca~e 2: 31-year-old caucasian woman, oro-antral fistula
after extraction of the 16 three months earlier. Several an-
tibiotic courses and sinus-washes with Soframicin | with-
out success: Pain and x-ray findings (opacification, no
bone destruction) indicated right maxillary sinusitis. Cald-
well-Luc operation performed and pathological examina-
tion revealed Aspergillosis. No relapse in 6 years.
Case 3: 30-year-old african male, a Behqet-patient, under
medication (colchicine, aspirin, ticlide) for 10 months,
showing chronic uv~itis in both eyes and presenting
asymptomatic left maxillary sinusitis. Dense bodies (diam.
3 mm) on x-ray in opaque sinus and clear perforation of
root-canal filling of tooth 26 with eugenate (zinc-oxide-
eugenol) overflow into the maxillary sinus. Apicectomy
w i t h surgical debridement of the sinus (Caldwell-Luc). Di-
agnosis confirmed by pathological examination. No re-
lapse in 4 years.
Case 4: 35-year-old caucasian woman, badly performed
root-canal treatments on 25 and 27. Treatment with i.v.
Penicillin + Metronidazole tw9 months before admission
because of extensive cellulitis of left cheel<. On x-ray, me-
tal-like dense bodies (diam. 4 mm) present in left maxillary
sinus. Caldwell-Luc performed, no relapse in 1 year. Diag-
nosis confirmed by pathological examination.
Case 5: 35-year-old caucasian woman with chronic left
maxillary sinusitis, present for 12 months and left untrea-
ted. Root-canal treatment of tooth 26, 18 months previ-
ously. Metal-like dense bodies in sinus on x-ray. Caldwell-
Luc operation performed and no relapse in 7 years. Patho-
logical confirmation of diagnosis of S. A.
Case 6: 30-year-old caucasian woman, posterior nasal
drip. N o evidence of dental factor. Sinns puncture per-
formed three months earlier (culture negative). Antibiotics
and local steroid therapy gave temporary improvement.
Standard x-rays and CT-scan now show presence of metal-
dense body within confines of opaque left maxillary sinus.
Caldwell-Luc performed and no relapse after 2 years. As-
pergillosis diagnosed on pathological examination. Rou-
tine culture remained negative.
Case 7: 36-year-old woman with posterior nasal drip. Si-
nus puncture 2 months previously (culture negative). Anti-
biotic and anti-histamine therapy without result. Radio-
logical evidence of eugenate-paste floating free in the left
maxillary sinus, after root-canal treatment of tooth 26.
Inflamation extended into opaque ethmoid sinus (strictly
left unilateral) and perforated medial wall of left maxillary
sinus. Caldwell-Luc procedure was combined with eth-
moid sinus curettage followed by one month of Nizoral|
(1 tablet daily). Diagnosis (and presence of eugenate) cou-
firmed by pathological examination. No relapse in 2
years.
Case 8" 57-year-old caucasian man with strictly unilateral
pansinusitis, invasion of left medial wall of maxillary sinus
and orbit. Chronic pain in left maxillary sinus (onset 4
months earlier) spread to retrobulbar area. Chronic poste-
r i o t nasal drip. Poor periodontal condition indicating pos-
sible dental origin. Recent holiday in India. Several courses
of broad-spectrum antibiotic therapy. Radiographs and
CF-scan showing opacity of all sinuses on the left with
J. Cranio-Max.-Fac. Surg. 18 (1990) 35
presence of dense particles in maxillary sinus. Medial si-
nus: and orbital walls destroyed (Fig. 3). Biopsies negative.
Through a lateral rhinotomy, all left paranasal sinuses
were cleared. Several biopsies and cultures taken from and
around mastic-like mass. The pathological diagnosis ex-
cluded malignancy and indicated S. A. Aspergillus found in
cultures of the specimen. No relapse in 4 years.
Case 9: 60-year-old caucasian woman with long-standing
diabetes, not kept under proper medical control. Recur-
rent frontal headaches (especially in tile supine position),
and recently vomiting, hiccup and loss of consciousness
(probably due to hypopotassaemia). N o evidence of intra-
cranial hypertension. CF-scan showed opacity of the left
sphenoid- and ethmoid sinuses on both sides, with clear
striae, running through tile cribriform plate into the dura
and frontal lobe. These appearances suggest Aspergillus-
filaments, as an alternative diagnosis to malignancy. Later-
al rhinotomy performed on either side, and spheno-eth-
moidectomy performed up to dura. Biopsy specimens
showed typical striae of Aspergillus. Initially, patient did
well under broad sprectrum antibiotics (Penicillin + Me-
tronidazole). After control of diabetes, patient transferred
to another hospital. Patient died 6 months later of a cereb-
rovascular accident, CT images showing intracranial
spread of Aspergilloma (Fig. 6). N o autopsy was per-
formed.
Case 10: 56-year-old obese caucasian male suffering from
rhinorrhoea, nasal obstruction (predominantly on right
side), and sinus fullness for one month. Moderate septal
deviation to the right, due to old nasal trauma. No history
of sinus problems, no medication, surgical history limited
to abdominal operations. Diminished translucency of right
maxillary sinus and presence of metal-dense foreign body
(diam. 6 mm) in centre of opacity. Root of tooth 13 ex-
tended into right maxillary sinus showing a poorly per-
formed rootcanal filling. Left maxillary sinus also showed
a local opacity, indicating a sinus polyp. Bilateral Cald-
well-Luc, extraction of tooth 13 and correction of the de-
viated septum. Mastic-like material found only in right
maxillary sinus, revealing Aspergillosis on pathological ex-
amination. Left maxillary sinus polyp negative for fungi.
Culture on Sabouraud's agar of all curretted materials re-
mained negative. No relapse over 5 months.
Results
In each centre we have found five cases of Sinus Aspergil-
losis: Cases 1-5 in the Paris unit and cases 6 - 1 0 in the
Leuven unit (Table 2). In this series:
- 80 % of the patients were in their fourth decade, 20 %
older "
- 70 % were female
- 70% were non-invasive forms according to Hora's
(1965) classification (cases 7, 8, 9)
- in 70% there was evidence of contamination of the
maxillary sinus, (71% by eugenate and 29 % via an oro-
antral fistula), vs. 20% in which there were circum-
stances indicating a higher probability of spore inhala-
tion (case 8 - tourism, case 9 - farmer's wife). 10%
could not be accounted for.
Treatment of our 10 cases comprised removal of all the
pathological sinus mucosa. In most cases tile currettage
was done through a classic Caldwell-Luc approach. As a
routine, the currettage was limited to the pathological area
 36 J. Cranio-Max.-Fac. Burg. 18 (I990) Christophe De Foer et al.

of the sinus mucosa. Only cases 7, 8 and 9 required more

extensive treatment.

Fig,4 Light micrograph of the Aspergillus-colony (P.A.S.-cofour-
ing, magnific x 15), showing the typical septate hyphae and the As-
pergillus heads, directed toward the periphery of the fungal mass
(case 9).
Discussion
Aspergillus is a fungus of the species of Ascomycetes,
which is found in different kinds of soil. Within the group
of fungi, Aspergillus is by far the commonest to produce
infection of the nose and paranasal sinuses (Savetsky and
Waltner, 1978). Three different subtypes are regarded as
possible parasites or saprophytes of the nose: A. Flavus, A.
Fumigatus and (rarely) A. Niger (Axelsson et al., 1978).
More than 90 % of the so-called "Aspergilloses" are pul-
monary infections. Besides, the respiratory tract is the
main "porte d'entr~e" for generalized A. infections, which
secondarily spread to other organs (Schrijver et al., 1983).
In contrast to this "metastatic" infection, the sinus is al-
most exclusively infected primarily; i.e. by direct inhala-
tion of the spores. Milosef and Mahgoub (1969) reported
on the largest series observed to date. Their 69 patients
were recruited in the tropical Sudan, where the disease is
endemic because of the high density of Asp. spores in the
dust and the frequent sand-storms. Other authors have
confirmed the favourable influence of a warm and moist
climate on the development of S.A (Hora, 1965; Warder et
al., 1976; McGuirt and Harrill, 1979; McGill et al.,
1980). The spores of A. flavus are found in the nasal se-
cretion of most of the Sudanese population.,Many Asp. in-
fections here develop in a spectacular way probably as a
result of the relatively late request for medical care (Milo-
sef and Mahgoub, 1969; Mahgoub," 1971; Veress et al.,
1973). However difficult it seems to exclude contact with
"atmospheres at risk" of spore-inhalation (increasing air-
traffic to Africa, as was seen in a case by Lowe and Brad-
ley in 1986; or tourism in India, as seen in our case no. 8),
it is likely that another pathogenic mechanism is involved
in the development of S.A. in our European conditions.

Table2 A survey of the 10 presented case reports

sex age site CT/x-ray assoc, path. factor peroperative finding culture

case 1 f 31 L. Max O dental implant mastic-like material n.m.

case 2 f 31 R. Max O oroantral fistula n.s. n.m.
case 3 m 30 L. Max O, D.P. Beh~et/eugenate mastic-like material n.m.
case 4 f 35 L. Max O, D.P. rootcanal perfor? n.s. n. m
case 5 f 35 L. Max O, D.P. ro~tcanal perfor? n.S. n.M.
case 6 f 30 L. Max O, D.P. -- n.s. neg.
case 7 f 36 L.M., E. S O, F. B., B.D. rootcanal perfor eugenate neg.
case 8 m 57 L.M., E., S, Orbit O, B.D. periodontitis/India mastic-like material Asperg.
case 9 f 60 Bilat E,, S. Brain O.B. D diabetes/farming mastic-like material n.m.
case 10 m 57 R. Max O, D.P. -- n.s. neg.
case 11 f 56 R. Max O, D.P. -- "~ mastic-like material n.m.

R. M(ax) = Right Maxillary Sinus

L.M, E, S, Orbit = Left Maxillary, Ethmoid and Sphenoid sinus and Orbital invasion
O = opacification of sinus on CT-scan or standard x-ray
D.P. = metaldense particles
'~ F.B. = foreign body (eugenate fragment)
B.D. = bone destruction
n.m. = not ment~0ned
n.s. = not specified
Sinus Aspergillosis J. Cranio-Max.-Fac. Surg. 18 (I990) 37

Legent et at. (1980) observed several cases of S.A. after

perforation of the maxillary sinus during endodontic
treatment in the maxillary dentition. In 50 % of 20 maxil-
lary Asp. sinusitises, eugenate paste was found floating
free in the maxillary sinus. This might indicate a probable
cause of chronic Asp. sinusitits. Moreover, in all 20 cases,
some factor in the maxillary dentition was found to be a
possible cause of the infection, the majority of patients be-
ing in good'general condition (Legent et al., 1980, 1982,
1984).
Legent comments on his hypothesis as follows:
-throughout the literature, the unilateral maxillary
localisation of S.A. is by far the most frequent one.
Though sometimes it is part of a pansinusitis, isolated
ethmoidal-, sphenoidal-, or frontal- sinusitis is rare (only
5 %, 13 % and 2 % respectively if the Sudanese cases are
not taken into account). (Schrijver et al., 1983, Glass,
1984).
- The combination of the immunosuppressive effect of
corticosteroids, when added to eugenate obturator-
pastes would especially favour the development of a
S.A.
Legent et al. (1982) do not exclude the possible climatic
factor. According to the authors, certain regions in France Fig.5 Sinus Aspergillosis, aetio-pathogenesis, possible develop-
(Bordeaux, Nantes) would have more cases to report than ment.
others. First pathway: direct spore-inhalation via nose
It is our opinion that both the "aerogenic" and the "den- - traditionally observed in (sub)tropical climats
togenic pathways can explain port of the pathogenesis of - explains (the rare) ethmoid and sphenoid S.A.'s.
S.A. Depending on clinical and radiological observations - impossible to exclude in any case, since spores omnipresent
(e. g. panoramic and tomographic images of the maxillary Second pathway: (iatrogenic) maxillary sinus contamination during
dentition), as well as the circumstances in which the pa- manipulations in maxillary dentition (implants, fistula, rootcanals)
tient lives (e. g. urban vs. rural area, profession, air-travel - probably more important in industrialised, urban area
to other climates, hygiene), the clinician may come to a - explains the predominantly unilateral maxillary sinus Iocalisation
correct attribution of the origin of the infection. In our 10 - does not explain why the majority of (iatrogenic) sinus perfora-
cases, either pathway seems to contribute to tile explana- tions do not develop S.A.-additional hygienic factor?
tion of the totality of the series. Possible invasion of vital structures
1) Orbit
In seven cases there was evidence of a "dental" factor (5 2) cribriform plate, brain
endodontic sinus perforations (case 3, 4, 5, 7, 10), 2 oro-
sinusal fistula (case 1, 2)).
Clinically, S.A. should be thought of in case of:
a) every sinusitis, that does not respond to antibiotics and
irrigation;
b) blood or greenish, grayish membranes (mastic-like) on
antral wash-outs; Fig.6 CT-scan
c) every strictly unilateral sinusitis; image showing in-
d) destruction of the bony sinus walls. tra-cranial spread
Radiologically, S. A. presents as an unilateral loss of trans- of the Aspergillo-
ma, after direct de-
lucency of the affected sinus. Eventually, metal-dense par-
struction of sphe-
ticles can be observed within tile confines of this opacity. noid bone (case 9).
They would be due to high calciumphosphate in tile in-
tracellular milieu of the necrotising Asp. cells (Kopp,
1985; Stammberger, 1985). We have observed such dense
particles on different radiographs (see figures 1 and 2) of
seven of our cases (3 to 8 and 10). However, all these par-
ticles were seen in the maxillary sinus, and in several cases,
they might well have been foreign bodies (e. g. eugenate in
case 3, 4, 5, 7 and 10).
Nevertheless, in cases 6 and 8, metallic-dense particles
were observed, while there was no context of endodontic
treatment in the neighbouring maxillary dentition. Zin-
reich et al. (1988) diagnosed 22 of 25 (76%) cases of fun-
gal sinusitis on CT images. They stated that the findings
on Magnetic Resonance Imaging would appear even more
characteristic of fungal sinusitis. They typical increased at-
38 J. Cranio-Max.-Fac. Surg. 18 (1990)
tenuation on a CT and the hypointense signal on an MRI
would be due to high concentrations of Calcium, Iron and
Manganese in the mycetoma.
Most often, the evolution of S.A. is benign, and resembles
any chronic bacterial sinusitis. The most important distinc-
tive characteristic however, is its potential to become inva-
sive at any stage. When confronted with a pseudo-tumou-
ral process in the maxillary sinus (cholesteatomas and
mugoc6eles are predominantly found in fronto-ethmoidal
sinuses), one should always consider the possibility of an
invasive S. A-(Juvanon et al., 1987).
lnvasive S.A. is a rare disease, but can be seen in patients
in otherwise perfect physical condition. Immunodepres-
sion enhances the chances of possible invasiveness (Warder
et al., 1976; Vanderstock et al., 1981). However, invasion
of the brain and orbits in healthy patients has been report-
ed several times (Young et al., 1970; Jahrsdoerfer et al.,
1979; Bahadur et al., 1983; Yumoto et al., 1985; Lowe
and Bradley, 1986).
Also in our series, two of our three invasive cases were in
perfect physical condition. These cases (case 7 and 8) sus-
tain the conclusions that invasive S.A. may occur in heal-
thy subjects. In the third case (case 9) there was evidence of
impaired defences (i. e. diabetes). In this case the outcome
of the intracerebral spread of the infection was, despite in-
tensive treatment, fatal to the patient.
The invasion of surrounding tissues is sometimes charac-
terised by pain (invasion of overlying skin) but can also
present as a painless, expanding, firm mass. Invasion of the
orbit is characterised by impaired vision and/or eye mobili-
ty, exophthalmia and temporo-occipital headaches. In the
case of ethmoidal invasion, the process will expand (as
does a carcinoma) via the path of least resistance, that is
the cribriform plate. Intra-cranial extension (as in case 9),
will very often have a fatal outcome. The differential diag-
nosis between S.A. and a carcinoma on radiographic find-
ings is a difficult, if not impossible task. Sometimes the
circumstances can be very misleading, as reported by Bris-
seau (1986): he reported a case of ethmoid S. A. in a wood-
worker, a profession known to be predisposed to adeno-
carcinoma in the ethmoid sinus. On the other hand, Asper-
gillosis can coexist with a carcinoma in the sinus. In such a
case one wonders which was the primary pathology (Tano-
ka, 1985)? Another differential diagnosis to be considered
is Mucormycosis. This presents as an obstructive mass, in-
volving the sinus in a way similar to Aspergillosis. Peroper-
atively, a comparable "mastic-like" material is found and it
can become as invasive.
The diagnosis of Aspergillic infection is based on the mic-
roscopic findings. Aspergillus has narrow (41am) septate
hyphae (Fig. 4), in contrast to Mucormycosis which has.
broader (6 to 50 [tm) rarely septate hyphae of uneven dia-
meter. Also, destruction of blood vessels (with eventually
haematogenous spread) is typical of Mucormycosis, since
Aspergillus does not invade blood vessels.
A positive culture on Sabouraud's agar does not provide
exact proof of the Asp. infection since spores are omni-
present in the atmosphere. However, culturing "fresh"
curretted material is o f additional value in identifying the"
subtypes.
The microscopic image of an Aspergilloma shows (after
staining with P.A.S. or-Gomori-Grocott) the typical
branched hyphae of the filaments, with the heads of the
Aspergilli, confined to the periphery of the fungal mass
Cbristopbe De Foer et al.
(Katzenstehl, 1983). In the invasive cases, the surrounding
tissues show signs of an immunological reaction, such as
fibrinoid changes of the blood vessels and extravasation of
lymphocytes; pseudotuberculae similar to those seen in
other conditions of delayed hypersensitivity. The sinus is
filled with a mucoid mass, in which eosinophylic cells, leu-
cocytes and Charcot-Leyden crystals are scattered through-
out the hyphae (Veress et al., 1973).
The only effective treatment of S.A. is total debridement
of the affected sinus(es). Depending on the clinical and ra-
diological findings, access will be gained through a trans-
oral antrostomy or through a lateral rhinotomy. Sinus-
wash-outs and/or conservative antibiotic-therapy are never
effective. Any chronic maxillary sinusitis, showing one or
more of the characteristics mentioned above should be
treated by surgical debridement without delay. Even
though many iatrogenic (e. g. implantological, endodontic)
sinus perforations remain trouble free, there is evidence
that in case of oro-sinusal fistula or spilling of eugenate-
paste into the sinus, a conservative approach (antibiotics
and corticosteroids) will enhance the (possibly invasive)
proliferation of the fungal mass (hvamoto et al., 1972;
Bambule and Grigoriu, 1982; Bassiouny et al., 1982). As
illustrated in our cases 7 and 8, surgery is also effective in
tile invasive forms. Radiation therapy is obsolete.
Some discussion exists on the additional use of Amphoteri-
cin B after surgery. However much its in vitro effective-
ness has been proved, the clinical use of Amphotericin B is
less evident.
Stevens (1981)suggested the use o f hyperbaric oxygen in
S.A., but to our knowledge, clinicfil reports of its use in
S.A. have not yet been published. In Mucormycosis, ad-
junctive hyperbaric oxygen therapy has already been
proved effective after surgical debridement. The rationale
for its use is that this treatment modality would increase
tissue oxygen concentration and reduce acidosis, even in
poorly perfused tissues.
Farmer (1985) stated that, in view of the results already
obtained by others, adjunctive hyperbaric oxygen should
be used in rhinocerebral Mucormycosis.
Indeed, in vitro studies by several investigators have shown
that oxygen in sufficient concentrations is fungistatic for
Mucor and Aspergillus. We suggest that hyperbaric oxy-
gen be used in invasive cases of S.A., when there is evi-
dence of extensive necrosis, and only as an adjunctive ther-
apy to surgery. It seems obvious that, since Aspergillus
lacks the predilection for invasion of blood vessels (charac-
teristic of Mucormycosis), resulting in thrombosis and in-
farction of the tissues, the usefulness of oxygen is doubtful
in S.A. In most cases, aeration of the sinus is a necessity
but t'he use of a hyperbaric oxygen chamber is cumber-
some and superfluous. The prognosis of S.A. fully de-
pends upon the early diagnosis and accurate surgery.
Unfortunately, serological screening is, in contrast to pul-
monary Aspergillosis, completely unreliable in S.A.
To some extend, the subtype of Aspergdlus 0. e. the more
virulent A. Flavus) and the site of the expanding mass (i. e.
proximity of cribriform plate or optical nerve-canal) are
decisive for the prognosis of the disease. Intracranial inva-
sion most often has a fatal outcome. (Gupta et al., 1973;
Miglets et al., 1978).
Sinus Aspergillosis
Conclusions
I n . c o n t r a s t to Mucormycosis, which is often discussed in
the oto-rhinolaryngological literature, Sinus Aspergillosis
is a rarely r e p o r t e d disease. One wonders if M u c o r is really
a m o r e frequent infection than Aspergillus. It is o u r guess
that most o f the cases of Sinus Aspergillosis seen in o u r
countries are first seen by oral surgeons, since the basis o f
the p r o b l e m often resides in the maxillary dentition. This
is in corfirast to the large series of " a i r b o r n " forms previ-
ously described in tropical countries. The majority o f these
S.A.'s was caused by more virulent species (A. Flavus) in a
different p o p u l a t i o n and climate. In our series, the majori-
ty o f cases were relatively "tranquil" forms with a dental
history. Possibly, they represent the "tip o f the iceberg" o f
a multitude o f Aspergillic sinusitises that are treated as an
o r d i n a r y sinusitis.
T w o o f o u r three invasive cases seemed to show an a i r b o r n
c o n t e x t rather than a dental one. There might be a differ-
ence in virulence o f the species that are inoculated via the
" a i r b o r n " instead of the "dental" p a t h w a y . It w o u l d be in-
teresting to investigate and culture maxillary sinusitises
m o r e often, especially if metal-dense particles are seen in
the sinus on a radiograph. A high index o f suspicion of the
diagnosis will p r o b a b l y reveal m o r e S.A. infections in the
future. "
Acknowledgements
The authors wish to express their sincere thanks to Dr. G. van Parijs
and Prof. van Damme (Dept. of Pathology - U.Z. Leuven), for their
excellent micrographic photographs and advice on the pathology.
Especially, they thank Dr. A. Cbarbit for his well-kept files on the
five Parisian cases which he had included in his thesis on the subject.
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