primary infection involves eyes , ears , larynx , lungs , and sinuses , followed by liver , spleen , bone , and meninges .
worldwide , aspergillus fumigatus is the most common species , followed by aspergillus niger and aspergillus flavus , whereas a. flavus is the most common species in india .
predisposing factors that promote fungal infections in the sinuses include polyps and stagnant secretions besides other factors like neutropenia , inappropriate use of antibiotics , immunosuppressive drugs , corticosteroids , uncontrolled diabetes mellitus ( dm ) , human immunodeficiency virus ( hiv ) infection , trauma , burns , and radiation therapy . in immunocompromised patients
, aspergillus leads to highly destructive lesions ; however , literature search shows invasive aspergillosis in non - neutropenic patients also .
clinico - radiological findings can be misleading as the lesions are locally destructive and mimic a neoplasm .
invasive fungal sinusitis ( ifs ) responds to conservative medical management and debridement ; hence , an early diagnosis by fine needle aspiration cytology ( fnac ) is mandatory to prevent undue surgery .
we report two patients presenting with swelling and pain in the maxillary region who were clinico - radiologically suspected of malignancy ; however , fnac in both the cases revealed fungal sinusitis ( fs ) .
fnac was performed in both cases using 22-gauge needle ; aspirate was whitish fluid ( case 1 ) and blood mixed ( case 2 ) .
the aspirates were processed as air - dried giemsa - stained smears ; cytomorphological features were suggestive of aspergillosis .
periodic - acid - schiff ( pas ) and silver methanamine ( sm ) stains were performed on the aspirate smears for further typing of fungus . however , considering the clinico - radiological suspicion of neoplasm , a biopsy was advised that confirmed fungus in both the cases . a 45-year - old female presented to the ear , nose and throat ( ent ) department with complaints of a painful swelling in the left maxillary region for 6 months .
there was no history suggestive of nasal obstruction , fever , recurrent infections or diabetes .
clinically , there was a tender swelling in the left maxillary region near the medial canthus .
computed tomography ( ct ) scan showed expansion of the maxillary sinus with bone erosion , suggestive of a malignancy . a 42-year - old male presented with complaints of headache , nasal discharge and swelling in right maxillary region for 8 months .
a bony hard swelling measuring 8  8 cm was palpated in the right maxilla reaching up to the infraorbital region .
ct scan showed an enhancing soft tissue density in the right maxillary sinus , suggestive of a proliferative lesion .
microscopic examination of aspirate smears revealed predominantly hemorrhagic background with many multinucleated foreign body giant cells ( gcs ) , and few inflammatory cells comprising eosinophils , plasma cells and lymphocytes . interspersed amongst these and within the gcs ,
based on the ct and cytological features , a diagnosis of ifs caused by aspergillus was suggested .
( a ) smear shows septate , fungal hyphae branching at acute angle in an acute inflammatory background ( giemsa , 250 ) and ( b ) a hyphae within the giant cell ( giemsa , 400 ) histopathological examination of biopsies from the maxillary sinus in both the cases showed abundant septate fungal hyphae , granulomatous inflammation , gcs and eosinophils ; pas and sm stains confirmed the type of fungus as aspergillus [ figure 2 ] .
culture from the serous material from sinusitis showed greenish white cotton wool growth at 37c on sabouraud 's dextrose agar ( sda ) , thus confirming the species as a. flavus .
sections show ( a ) aspergillus in necrotic background ( h and e , 250 ) , ( b ) fungal hyphae in giant cell ( h and e , 400 ) , ( c ) many eosinophils and hyphae ( h and e , 250 ) , special stains highlighting the fungal morphology ( d ; pas , 250 ) and ( e ; silver methanamine , 250 ) the former patient was treated initially with intravenous amphotericin - b and endoscopic debridement , followed by oral itraconazole ; further , she had to undergo partial maxillectomy in view of frequent recurrences and bone involvement .
a 45-year - old female presented to the ear , nose and throat ( ent ) department with complaints of a painful swelling in the left maxillary region for 6 months .
there was no history suggestive of nasal obstruction , fever , recurrent infections or diabetes .
clinically , there was a tender swelling in the left maxillary region near the medial canthus .
computed tomography ( ct ) scan showed expansion of the maxillary sinus with bone erosion , suggestive of a malignancy .
a 42-year - old male presented with complaints of headache , nasal discharge and swelling in right maxillary region for 8 months .
a bony hard swelling measuring 8  8 cm was palpated in the right maxilla reaching up to the infraorbital region .
ct scan showed an enhancing soft tissue density in the right maxillary sinus , suggestive of a proliferative lesion .
microscopic examination of aspirate smears revealed predominantly hemorrhagic background with many multinucleated foreign body giant cells ( gcs ) , and few inflammatory cells comprising eosinophils , plasma cells and lymphocytes . interspersed amongst these and within the gcs ,
based on the ct and cytological features , a diagnosis of ifs caused by aspergillus was suggested .
( a ) smear shows septate , fungal hyphae branching at acute angle in an acute inflammatory background ( giemsa , 250 ) and ( b ) a hyphae within the giant cell ( giemsa , 400 )
histopathological examination of biopsies from the maxillary sinus in both the cases showed abundant septate fungal hyphae , granulomatous inflammation , gcs and eosinophils ; pas and sm stains confirmed the type of fungus as aspergillus [ figure 2 ] .
culture from the serous material from sinusitis showed greenish white cotton wool growth at 37c on sabouraud 's dextrose agar ( sda ) , thus confirming the species as a. flavus .
sections show ( a ) aspergillus in necrotic background ( h and e , 250 ) , ( b ) fungal hyphae in giant cell ( h and e , 400 ) , ( c ) many eosinophils and hyphae ( h and e , 250 ) , special stains highlighting the fungal morphology ( d ; pas , 250 ) and ( e ; silver methanamine , 250 ) the former patient was treated initially with intravenous amphotericin - b and endoscopic debridement , followed by oral itraconazole ; further , she had to undergo partial maxillectomy in view of frequent recurrences and bone involvement .
fungal sinusitis constitutes 69% of all the rhinosinusitis.[68 ] clinically , it presents as either an acute fulminant sinusitis or chronic invasive sinusitis .
the former is largely attributed to mucor and the latter is mainly due to aspergillus .
the acute form is a life - threatening condition , usually seen in immunocompromised patients with severe neutropenia or dm , and is associated with significant visual and neurological impairments in survivors , and sometimes mortality .
clinically , these patients may present with rhinorrhea , headache , nasal obstruction , proptosis , facial and periorbital pain mimicking infections ( mucor , tuberculosis , osteomyelitis ) , inflammatory lesions ( rhinoscleroma , wegener 's granulomatosis ) and malignant tumors of the nose and paranasal sinuses .
non - invasive fs includes allergic and fungal ball and does not need extensive surgery , while most of the ifs patients are unresponsive to conservative management and require appropriate antifungals with local debridement .
early and definitive diagnosis of ifs is mandatory that will rule out other differential diagnoses , especially neoplasm , and will help clinicians for appropriate management and in the follow - up of patients .
both magnetic resonance imaging ( mri ) and ct can help establish a diagnosis of ifs .
bone involvement and erosion is more delineated on ct , while soft tissue extensions , vascular invasion and cavernous sinus involvement are more appreciated on mri . both the imaging techniques , however , are not definitive and often fail to differentiate an infectious process from a neoplastic one . definite diagnosis of fs depends upon the demonstration of the fungus on aspirate smears or a biopsy .
fungal culture is complimentary to morphology and required for species identification ; but samples submitted for culture may not be representative , and not all the fungi grow on culture media .
aspergillus can be easily differentiated from mucor on morphology , as the latter is characterised by broad , non - septate hyphae branching at right angle . in the present cases ,
both the patients were immunocompetent , middle aged and clinico - radiologically suspected of malignancy ; however , they were diagnosed on fnac as fungal sinusitis and prevented from undue surgery .
species identification is not much relevant in patients management , but is of epidemiogical significance , since it depends upon various geographical locations , thus aiding diagnosis in difficult cases .
this report emphasizes on the early diagnosis of ifs , which can be managed conservatively preventing the morbidity and mortality in these patients .
cytology , being an easily available , minimally invasive and inexpensive procedure , can be used as initial diagnostic modality in cases of ifs .
 fungi have emerged as important etiological agents for chronic sinusitis . 
 invasive aspergillosis has been reported in immunocompromised individuals or diabetics ; however , it is uncommonly seen in immunocompetent patients . 
 definitive diagnosis of these lesions is based on histological examination and fungal culture . 
 we report two cases of invasive maxillary lesions in immunocompetent patients , clinically suspected of malignancy ; however , fine needle aspiration cytology showed fungal hyphae , morphologically suggestive of aspergillus , which was later confirmed on histopathology . 
 aspiration cytology thus plays a crucial role in the early and definitive diagnosis of fungal sinusitis in cases clinico - radiologically suspected of malignancy . 
 an early diagnosis will help the clinician for early and appropriate management and follow - up in order to decrease the high morbidity and mortality associated with it . 