Oral Biol Res 2023; 47(2): 67-69  https://doi.org/10.21851/obr.47.02.202306.67
Removal of fungus ball of the right maxillary sinus via LeFort I osteotomy: A case report
Min-Soo Kim1† , Da-Woon Kwack1† , and Se-Jin Han2*
1Resident, Department of Oral and Maxillofacial Surgery, College of Dentistry, Dankook University, Cheonan, Republic of Korea
2Adjunct Professor, Department of Oral and Maxillofacial Surgery, College of Dentistry, Dankook University, Cheonan, Republic of Korea
Correspondence to: Se-Jin Han, Department of Oral and Maxillofacial Surgery, College of Dentistry, Dankook University, 119, Dandae-ro, Dongnam-gu, Cheonan 31116, Republic of Korea.
Tel: +82-41-550-0271, Fax: +82-504-023-7540, E-mail: hanimplant@hanmail.net
These authors contributed equally to this work.
Received: May 9, 2023; Revised: May 25, 2023; Accepted: May 28, 2023; Published online: June 30, 2023.
© Oral Biology Research. All rights reserved.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
A 27-year-old male patient was referred to the department of the oral and maxillofacial surgery for an orthognathic surgery. The radiographic examination revealed opacification of the right maxillary sinus. An orthognathic surgery was planned, which involved approaching the right maxillary sinus lesion simultaneously after LeFort I osteotomy. It was possible to remove the lesion via curettage simultaneously for both the cosmetic aspect and maxillary sinus without performing the operation twice. In most cases, surgery is performed using endoscopic sinus surgery or the Caldwell-Luc procedure. Therefore, this is a rare case of fungus ball removal via LeFort I osteotomy.
Keywords: Aspergillus; Fungi; Orthognathic surgery
Introduction

The fungus ball, or aspergillus mycetoma of the maxillary sinus is a noninvasive fungal infection. It is characterized as a dense conglomeration of fungal hyphae, usually localized in the maxillary sinus of immunocompetent patients [1]. Aspergillus fumigatus is most frequently detected fungus in histopathological examination among fungus ball patients [2]. Etiopathogenesis of fungus ball is uncertain [3].

Fungus ball may be found with 2 different clinical features, symptomatic or asymptomatic. Symptomatic patients can have chronic sinusitis with nasal secretions, pain, and hyposmia. Asymptomatic patients usually often diagnosed after routine radiographic examinations [4]. Definitive diagnosis is obtained only after histopathological examination [5].

Surgical removal of the sinus fungal ball is performed using endoscopic sinus surgery (ESS) or the Caldwell-Luc procedure. General or local antifungal drugs are not indicated [4]. Bachesk A reported fungus ball removal by LeFort I osteotomy with using antifungal drugs [5].

The purpose of this study is to report a clinical case of fungus ball removal by LeFort I osteotomy without using antifungal drugs. This is unusual case that treatment during the orthognathic surgery. Patient consent was taken.

Case Description

A 27-year-old male patient was referred to the department of the oral and maxillofacial surgery for orthognathic surgery. He had no history of systemic disease. On radiographic examination, opacification of the right maxillary sinus was found (Fig. 1, 2). He did not complain of related symptoms such as chronic sinusitis. Any specific symptoms wasn’t found in endodontic assessment of the maxillary tooth. Orthognathic surgery planning was established and planned for approach right maxillary sinus lesion simultaneously after LeFort I osteotomy.

Fig. 1. (A) Coronal cone-beam computed tomography (CBCT) shows almost complete antral opacification with calcification. (B) Axial CBCT shows almost complete antral opacification with calcification.

Fig. 2. A panoramic view shows opacification of right maxillary sinus. L, left.

After LeFort I osteotomy brown and foamy mass was found in the right maxillary sinus (Fig. 3). Based on findings, hypotheses of fungus ball was considered. Total curettage of the maxillary sinus and biopsy of the collected mass from right maxillary sinus was performed. Biopsy result was fungus ball suggestive of aspergillus (Fig. 4).

Fig. 3. Lesions removed from the right maxillary sinus. Brown and foamy mass was shown.

Fig. 4. Histopathologic photograph show presence of thick fungal hyphae (H&E stain; ×400).

During a 1-year follow-up of post-surgery without antifungal drugs, no evidence of opacification on radiographic examination (Fig. 5).

Fig. 5. A panoramic view of 1yr after surgery. No evidence of opacification of right maxillary sinus. R, right.
Discussion

Fungus ball of the maxillary sinus is a rare disease and mostly diagnosed in elder immunocompetent patients [6]. Aspergilloma is symptomatic only after a long period of fungal infection [7]. Diagnosis of fungus ball is often difficult and inadequate [8]. Radiographic exam is an important exam to assist diagnosis. In this case excisional biopsy was done to clarify diagnosis after identifying opacification of right maxillary sinus in asymptomatic patients.

Currently, the surgical method to remove the fungal ball is through ESS or Caldwell-Luc procedure [4,9,10]. Alternatively, an endoscopically assisted osteoplastic approach via anterior maxilla approach is also introduced [1]. In our case, after all orthodontic preparation for orthognathic surgery were completed, it was referred to proceed orthognathic surgery, so we decided to remove the maxillary right lesion at the same time as orthognathic surgery. This method has the advantage of being able to observe the maxillary sinus immediately after LeFort I osteotomy. Effective treatment for this type of infection depends on surgical debridement. It was possible to remove the lesion by curettage both the cosmetic aspect and the maxillary sinus at one time without performing the operation twice. In most cases, surgery is performed through ESS or Caldwell-Luc procedure, and a case in which the fungus ball is removed through LeFort I osteotomy is rare.

Funding

None.

Conflicts of Interest

The authors declare that they have no competing interests.

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