Case Report :

Fungus Ball Mimicking Rhinolith in the Right Nasal Cavity with

Right Maxillary Rhinosinusitis and Deviated Septum

Presentan : Yayan Akhyar, MD

Day/Date : Wenesday/ 18th of March 2020
Time : 07.30 AM
Place : Conference Room Departement of ORL-HNS
dr.M.Djamil General Hospital
Note Person : Bobby Setiawan, MD
Opponent : Dian Pratama Putra, MD
Moderator : Dr. Effy Huriyati, MD, ORL-HNS (C), FICS
Tutor : Dolly Irfandy, MD, ORL-HNS (C), FICS
Guest Consultant : Yenita, MD, M.Biomed, Sp.PA

Otorhinolaryngology - Head and Neck Surgery Department

Faculty of Medicine Andalas University dr. M.Djamil General
Hospital Padang
2020
 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS ANDALAS
FAKULTAS KEDOKTERAN
Bagian Telinga Hidung Tenggorok Bedah Kepala Leher
(Department of Otorhinolaryngology Head and Neck Surgery)
Jl. Perintis kemerdekaan, Padang Telp. (0751) 37194, 810900, Fax. (0751) 37194
Website : http://tht.fk.unand.ac.id Email : tht_fkunand@yahoo.com

LEMBAR PERSETUJUAN

Judul : Fungus Ball Mimicking Rhinolith in the Right Nasal Cavity with Right
Maxillary Rhinosinusitis and Deviated Septum
Presentan : dr. Yayan Akhyar

Laporan Kasus ini telah diperiksa dan telah disetujui untuk dipresentasikan pada acara ilmiah
PPDS THT-KL FK Unand/ RSUP. Dr. M. Djamil Padang

Padang, 10 Maret 2020

Diketahui, Disetujui,
Kolit, Pembimbing,

dr. Al Hafiz, Sp.THT-KL(K), FICS dr. Dolly Irfandy, Sp.THT-KL(K), FICS

 Fungus Ball Mimicking Rhinolith in the Right Nasal Cavity with
Right Maxillary Rhinosinusitis and Deviated Septum

Yayan Akhyar

Abstract
Introduction: Fungus ball is extra-mucosal accumulation of degenerative fungal
hyphae especially in cases of chronic paranasal sinus inflammation. Fungus ball in
the nasal cavity is a very rare case. In some cases, fungus ball can be diagnose as
rhinolith due to the appearance at the physical and nasal endoscopic examination
which more or less resembles rhinolith Case report: Reported one case of a 50-
year-old woman with diagnosis fungus ball in right nasal cavity, right chronic
maxillary rhinosinusitis, septal deviation. Conclusion: Fungus ball is an important
differential diagnosis for rhinolith or foreign body in nasal cavity. CT scan may be
able to distinguish between fungus ball and rhinolith in addition to histopathology
examination as a gold standard. Endoscopic sinus surgery (ESS) is the treatment of
choice for fungus ball in the nasal cavity.
Keywords: fungus ball, rhinolith, nasal blocked, Endoscopy Sinuses Surgery (ESS)

Abstrak
Pendahuluan: Fungus ball adalah akumulasi hifa jamur degeneratif ekstra mukosa,
khususnya pada kasus-kasus peradangan kronis sinus paranasal . Fungus ball pada
kavum nasal merupakan kasus yang jarang. Pada beberapa kasus, fungus ball dapat
terdiagnosis sebagai rhinolith dikarenakan tampilan pada pemeriksaan fisik dan
nasoendoskopi yang menyerupai rhinolith. Laporan kasus: Dilaporkan satu kasus
seorang wanita berusia 50 tahun dengan diagnosis fungus ball di kavum nasal
kanan, rinosinusitis kronis maksila kanan, dan septum deviasi. Kesimpulan:
Fungus ball adalah diagnosis banding penting untuk rhinolith atau benda asing di
kavum nasal. CT scan dapat membantu membedakan antara fungus ball dengan
rhinolith, selain pemeriksaan histopatologi sebagai standar emas. Bedah sinus
endoskopi (BSE) adalah penatalaksanaan pilihan untuk fungus ball di kavum nasal.
Kata kunci: Fungus ball, rhinolith, hidung tersumbat, Bedah Sinus Endoskopi
(BSE)

INTRODUCTION (90%), followed by Aspergillus niger

Fungus Ball
Fungus ball is extra-mucosal
accumulation of degenerative fungal
hyphae especially in cases of chronic
paranasal sinus inflammation.1
Nowadays, the term ‘fungus ball” has
replaced the terms ‘mycetoma or
aspergilloma’. Aspergillus fumigatus
is reported as the most common
pathogenic organism of fungus ball
and Aspergillus flavus.2 However, in
the Middle East, A. flavus is more
common than Aspergillus fumigatus.3
Commonly case is infection of
isolated paranasal sinuses without any
mucosal invasion around it. Patients
may experience pain in the sinuses or
other parts involved.4 Fungus ball is
commonly found in the paranasal
sinuses, mostly in the maxillary sinus,

1
followed by the sphenoid sinus,
ethmoid sinus, and the frontal sinus in
succession.5 Sinus fungus ball could
erode the sinus wall causing facial
pain or obstruct the sinus ostium
resulting in secondary bacterial
infections.6
Fungus ball in the nasal cavity
is a very rare case and with unknown
etiology.7 Presence of a contracted
sinus and a wide meatus, previous
dental treatment, poor oro-dental
hygiene and previous surgery causing
mucosal trauma, have been suggested
as possible predisposing factors,
however, if a fungus ball has to
develop in any cavity, the
pathogenetic mechanism should be
the presence of an ostial closure,
which will trap fungal spores in an
anaerobic environment favouring
fungal growth and further
accumulation of fungal salts would
give it a bony hard consistency.7,8
Figure 1. Fungus ball in the nasal cavity
The symptomatology is
typical of a foreign body or rhinolith,
with unilateral nasal obstruction,
headache or facial pain due to sinus
inflammation caused by blocked
ostia, postnasal drip, and nocturnal
cough and cacosmia. Endoscopic
examination usually reveals the
presence of a mass in the nasal cavity,
associated with foul smelling
discharge. Imaging and culture of the
discharge usually clinches the
diagnosis in most cases. The fungal
concrement phenomenon suggests
that the increased density of fungus
balls is due to the presence of
deposition of phosphate and sulfate
salts of calcium in the necrotic centre
of the fungal mass.7,8
The diagnosis of fungus ball is
confirmed by microscopic
examination and specimen culture.
Enlargement of concha media with
heterogeneous opacity on CT can be a
consideration for directing the
diagnosis of Fungus ball.9 The only
effective management of fungus ball
cases in the sinus or nasal cavity is
surgical removal.4
Figure 2. CT scan of fungus ball in left
nasal cavity.10
Rhinolith
The term ‘rhinolith’ arises
from the Greek words ‘rhina’ and
‘lithos’, meaning nose and stone.11
Rhinolith is a classification mass
2
found in nasal cavities. Rhinolith is
also called nasal calculi or concretion
of the nose, and it is not commonly
found. First discovered by Bartholin
in 1654.12 Rhinolith occurs because of
the foreign body which has long
stayed in the nose (for example since
childhood), then covered by deposits
of calcium or magnesium salts as
phosphate or carbonate bonds derived
from lacrimal. Calcification of a
foreign body in the nose used to be
known as false rhinoliths or true
rhinoliths. At present, these terms
have been replaced with exogenous
and endogenous, depending on
whether or not there is a nucleus.
Rhinolith can be formed from
material outside the human body that
enters the nose and is left in the nasal
cavity such as cherry-shaped stones,
stones, nasal swabs that left behind, or
this kind of thing called exogenous.
Endogenous rhinolith are developed
materials that originate around the
body itself, for example, ectopic teeth
in the maxillary sinus, bone
sequestered, dried blood clots in the
nasal cavity, and solidified mucus.
About 20% of rhinolith comes from
endogenous material.13
In general, rhinolith consist of
90% inorganic material, with the
remaining 10% made from organic
material inserted into the lesions of
nasal secretions. Salts that do not
dissolve in nasal secretions form a
calcification as large as a foreign
body or a long-lasting blood clot.
discharge in chronic sinusitis can lead
to the formation of calcified masses in
the nasal cavity. Rhinolith is mainly
made of phosphate and calcium
carbonate. Sometimes also formed by
magnesium phosphate, sodium
chloride and magnesium carbonate.
This salt can also come from
secretions of nasal mucosa, tears, and
inflammatory exudate.12 In most
cases, rhinoliths are located in the
inferior nasal meatus. The symptoms
of rhinolith vary from mild with a
slight discharge or blockage from one
side of the nose to a severe one with
severe structural changes. Small sized
rhinolith are usually asymptomatic.
Large rhinolith can cause unilateral
rhinorrhea, nasal pain, nasal
obstruction, foul smelling breath,
epistaxis, nasal or facial swelling,
headache, sinusitis, anosmia, and
epiphora. Epistaxis and neuralgia
pain arise due to ulceration of the
surrounding mucosa.13,14
Figure 3. Nasoendoscopy of rhinolith in
the nasal cavity.15
The diagnosis of rhinolith is
based on physical examination, nasal
endoscopic examination and
computerized tomography (CT) of the
naso-sinus cavity. Although generally
asymptomatic, rhinolith can be
present in severe forms due to
infectious and mechanical
3
complications.16 Examination of a
paranasal sinus CT scan is
recommended because of its
sensitivity of seeing small amounts of
calcification and can also provide
information about adjacent structures
and help determine the boundary of
rhinoliths with structures its
surroundings are fused. On paranasal
sinus CT scan, a hyperdense mass
was seen in the nasal cavity,
squeezing and helps in identifying the
extent of the lesion and the choice of
surgical approach.11,17
Figure 4. Rhinolith in the right nasal
cavity.10
Management of rhinolith is
extraction by endoscopic nasal
surgery.16 Surgical removal of
rhinoliths, debridement, and infection
control with the use of antibiotics is
the treatment of choice for rhinoliths,
which can be done using local or
general anesthesia. If the stone size is
large, the surface is irregular, and it
affects the inferior nasal concha of the
sinister, then the patient must undergo
surgery using general anesthesia.
Rhinolith is removed using nasal
forceps. Most rhinolith can be
removed through the anterior nares.
Large mass sizes need to be crushed
first and then removed in the form of
small pieces. If the mass is very large,
hard, and the surface is irregular, it is
necessary to do a lateral
5,7,9
rhinotomy.
CASE REPORT
A 50-year-old woman came to
the RSUP Dr. M. Djamil Padang
outpatient clinic on February 20, 2019
with a blocked right nasal cavity since
a year ago. There was headaches
intermittently, not affected her daily
activity. There was sensation of nasal
mucus flowing down to the throat,
since last year. There was no thick
nasal mucus with smelly odor came
out from the nose. There was no blood
came out from the nose. There was
history of blood came out from the
right nasal cavity since 6 months ago,
last one was 2 weeks ago. There was
no decrease of smelling. There was no
pain and no fullness sensation of the
cheek. There was no history of trauma
of the nose. There was no history of
toothache. There was no history of
asthma. There was no history of
sneezing more than 5x when exposed
to dust. There was no history foreign
body inserted to the nose. the patient
does not smoke. There was no history
of diabetes. There was no history of
hypertension.
On physical examination
obtained general condition was
moderate, cooperative composmen-
tis, blood pressure 137/73 mmHg,
pulse rate 78x/ minute, respiratory
rate 20x/ minute, and temperature was
36.7 o
C. On nasoendoscopic
examination found:
4
Tabel 1. Patient’s nasoendoscopic right posterior nasal cavity rhinoliths,
examination right maxillary sinusitis, and septal
Right Left deviation.
Nasal Narrow, there Wide The diagnosis in this case was
cavity was foreign suspicious rhinolith in right nasal
body black-
brown in cavity, right chronic maxillary
color between rhinosinusitis, septal deviation. The
inferior patient is planned to undergo an
turbinate and
endoscopy sinus surgery (ESS) in
septum
Inferior general anesthesia. Laboratory tests
turbinate Eutrophy Eutrophy were performed with the result Hb:
13.8 gr/ dl, leukocytes: 8,070/ mm3,
Color of Pink Pink
hematocrit: 44%, platelets: 344,000 /
Inferior
turbinate mm3, PT: 10.2 seconds (9.2-12.4),
APTT: 37.5 seconds (28.4-41.4).
Middle Eutrophy Eutrophy
turbinate

Middle Opened Opened

meatus

Secret Mucopurulen (-)

Septal Septal (+) cryst

deviation(-)

Figure 6. Paranasal CT Scan of the

Figure 5. Nasoendoscopy of the patient's
right nasal cavity
The paranasal sinus CT scan
on February 22, 2019 with axial and
coronal slice, a 2 mm slide incision
without contrast revealed a thickening
of the right maxillary sinus. The
conclusions match the description of
patient
On July 26, 2018 surgery was
performed on the patient. The patient
on supine position with head elevated
for 30o in general anesthesia. Aseptic
and antiseptic procedures are carried
out on the operative field and a sterile
cover sheet is placed. Nasoendoscopy
is held with the left hand, scope 0o is
inserted into the nasal cavity.
Evaluation of the right nasal cavity:

5
nasal cavity was narrow, inferior signs monitoring, observation for
turbinate was eutrophy, middle signs of bleeding, fasting until the
turbinate was eutrophy, there was patient is fully conscious or normal
black-brown foreign body shown bowel sounds. Patients were given
between inferior turbinate and ringer lactate dripped with 1 ampoule
septum, medial meatus was open, of ketorolac for 8 hours/ flask,
there was mucopurulen secretions. ceftriaxone injection 2 x 1 gram
Left nasal cavity: nasal cavity was intravenous (iv), dexamethasone
wide, inferior turbinate was eutrophy, injection 3 x 5 mg iv.
middle turbinate was eutrophy,
medial meatus was open, there was
septal deviation. An adrenaline :
lidocain (1:4) packing was placed on
both nasal cavities and then awaited
for 10 minutes. Foreign body
extraction is done using alligator
forceps, the entire pieces of foreign Figure 7. Post extraction suspicious
body is removed until there is no rhinolith from the right nasal cavity
remaining in the nasal cavity. Parts of
Day 3 postoperative, there
foreign bodies are put in plastic
was no fever, there was no blood
containers with formaldehyde for
coming out from the mouth, there was
histopathological examination.
no bleeding from nasal packings,
Bleeding is controlled by placing a
there was minimal nasal pain, there
temporary packing in the right nasal
was no bloody tears, there was no
cavity. Infiltration with 1: 200,000
fullness sensation of the ears.
adrenalin was performed on the
Anterior nasal packings were
mucosa of the right uncinate process
removed, evaluation of nasal cavity;
and the right middle turbinate. An
nasal cavities were wide, inferior and
uncinectomy is performed on the
middle turbinate were eutrophy, there
right uncinate process using the back-
was hyperemic mucosa, there was
bitter until all parts of the uncinate
mucoid discharge, there was clotting,
process are removed. The right
there was no crusting, there was no
maxillary sinus using bent suction
pouring blood, there was no foreign
with the help of a 30o scope. The nasal
body. Patient brought a culture
cavity was re-evaluated, then nasal
examination and sensitivity test of
packings were placed on both nasal
nasal discharge with the result stated
cavities with the help of the ½ killian's
"no growth". Patients was given
speculum and then fixed to a gauze
cefixime 2 x 200 mg tablet, ibuprofen
placed on the front of the nose.
3 x 400 mg tablet. Patients was
Operation was finish.
scheduled to control to ORL-HNS
Post-operative instructions
0
outpatient clinic 1 week later or after
were 30-45 head elevation, vital

6
the results of histopathology
examination obtained.
Ten days postoperative, there
was no nasal congestion, there was no
blood came out from the nose and
mouth, there was no pain in the nose,
evaluation of nasal cavity; nasal
cavities were wide, inferior and
middle turbinate were eutrophy, there
was no hyperemic mucosa, there was
no discharge, there was no clotting,
there was minimal crusting, there was
no pouring blood, there was no
foreign body. Histopathology
examination result of the foreign
body specimens suspicious rhinolith
from the patient's nasal cavity; pieces
of tissue consisting of necrotic tissue
that contains a group of fungal spores
(Aspergillus sp), and the conclusion
stated that microscopic images are
convenient with fungus ball and no
malignant signs.
Figure 8. Microscopic images of
patient’s specimen, consisting of
necrotic tissue that contains a group
of fungal spores
Patients were treated for
crusting using alligator forceps per
endoscopy, and were given 0.9%
natrium chloride for nasal wash.
Patients was scheduled to control to
ORL-HNS outpatient clinic 2 weeks
later, but patient did not come.
DISCUSSION
A case was reported of a 50-
year-old woman who came to the
ORL-HNS outpatient clinic of RSUD
Dr. M. Djamil Padang with a
diagnosis suspicious rhinolith at right
nasal cavity, septal deviation, and
right maxillary rhinosinusitis.
Patients was treated by Endoscopic
Sinus Surgery (ESS) in general
anesthesia, extracted foreign body
specimens were sent for
histopathology examination.
Rhinolith which also referred
to as nose stone is a calcareous
concrete that arises secondary to all or
part of intranasal foreign bodies.10,18
Royal19, stated that the diagnosis of
rhinolith is usually made by finding a
complaint of unilateral nasal
obstruction, inspection with the help
of rhinoscopy and endoscopy
obtained masses or nodules with clear
or unclear boundaries. Endoscopy
plays an important role in the
evaluation of rhinolith levels without
risking radiation exposure, and CT
scan images appear to be
homogeneous with high density in the
peripheral section and lower density
in central areas.19 CT scan also
provides good visualization to
determine the location of rhinoliths.20
The diagnosis of rhinolith in
these patients made based on
anamnesis, physical examination,
endoscopic of nasal cavity and
radiology examination of the patient.
7
Unilateral nasal obstruction, a
blackish foreign body appearance in
the right nasal cavity and CT scan of
the nasal sinuses that gave an image
in accordance with the image of
rhinolith. Intraoperative suspicious
rhinolith extraction was performed to
patients in general anesthesia with
visualization using nasoendoscopy.9
The patient also diagnosed chronic
right maxillary rhinosinusitis and
septal deviation, performed
uncinectomy, sinus irrigation, and
septoplasty. Seth,21 stated in their
case report rhinoliths may cause
rhinosinusitis, erosion of the nasal
septum and the medial wall of the
maxillary sinus and perforations of
the palate. Rhinosinusitis and septum
deviation in most of the literature is
stated as a complication of rhinolith
that has been occurred in the nasal
cavity, but the pathogenesis sequence
of this event cannot be ascertained
because the possibility of
rhinosinusitis discharge concretion
that act as nidus and disruption of
nasal cavity air flow in septal
deviation cases could be predisposes
the formation of rhinolith.
Specimens extracted from the
patient's right nasal cavity were sent
to the Anatomic Pathology
Department for histopathology
examination as the gold standard for
establishing the diagnosis.
Histopathological results were
obtained a week postoperatively with
the results pieces of tissue consisting
necrotic tissue and a group of fungal
hyphae spores (aspergillus), the
microscopic features are convenient a
fungus ball, and no sign of
malignancy. The results of the
histopathology examination
determine the definitive diagnosis of
the patient in this case which was
originally diagnosed as rhinolith in
the right nasal cavity was change to
fungus ball in the right nasal cavity.
Oskiriz1, in his case report
conveyed a definite diagnosis of
fungus ball primarily based on
macroscopic and histopathological
appearance, because culture results
were often negative (70% of cases).
Invasive form of fungus ball is also
determined by histopathological
examination. Microscopic features
reveal intra-sinus hyphal masses
without invasion resembling the
morphology of aspergillus with the
PAS and Grocott’s staining
22
methods. In our patient specimen,
hematoxyline eosin (HE) used as a
staining method and gives good
results and can clearly identify
microscopic specimens. Badankar7,
in their case report stated the result of
histopathology examination in their
patients was showing pieces of tissues
consisted necrotic tissue that
contained a group of fungal spores
(aspergillus), convenient for fungus
ball. In their case report, which was
originally diagnosed as rhinolith, the
diagnosis was change as a fungus ball
in the right nasal cavity.7
Fungus Ball in the paranasal
sinuses is a relatively common case.
However, the presence of fungus ball
in the nasal cavity is very rare. The
diagnosis can be mistaken for
rhinolith because of its clinical
8
appearance, which is more or less
mimicking rhinolith.7,22 Endoscopic
examination usually reveals a mass in
the nasal cavity, associated with a
foul-smell discharge. Imaging
examination and specimen culture are
usually very helpful in making a
diagnosis in many cases. Although
the management is similar, there are
subtle differences in imaging that can
help in establishing the diagnosis of
fungus ball in the preoperative nasal
cavity.7 The fungus concretion
phenomenon shows that the increase
in fungus ball density is due to the
deposition which can be specifically
distinguished from a rhinolith, which
shows an increase in peripheral
density on a CT scan.7,8 Similarities in
anamnesis, physical examination, and
the appearance of radiological
examinations result were possible
causes of incorrect diagnosis in this
patient. Typical symptoms for fungus
ball, foreign body or rhinolith in the
nasal cavity are unilateral nasal
obstruction, headaches or facial pain
due to sinus inflammation caused by
blocked ostium, postnasal drips, and
nocturnal coughing.8
Aspergillus is a fungus
belonging to the species of
Ascomycetes. Its presence is
ubiquitous, generally involving
immunocompromised patients but
rarely can also affect healthy subjects.
Transmission is primarily through
inhalation but can also occur through
an iatrogenic. The most common
species pathogenic to humans are
Aspergillus Fumigatus followed by
Aspergillus Niger and Aspergillus
Flavus. Hypoxic conditions, as occurs
in the paranasal sinuses, promotes
pathogenicity.23,24 Other conditions
reported favor fungal infections are
diabetes, long-term treatments
(antibiotics and cortisones), radio and
chemotherapy, immunosuppressive
treatments, and immunodeficiency
diseases.1,25
Our patient had no history of
diabetes, immunodeficiency,
allergies, or any systemic disease.
However, it would be better if the
patient's immune status confirmed by
laboratory finding such as peripheral
blood differential cell count to
describe the activity of the patient's
cellular immune system. Kim,26
stated in their case report bacteria or
yeast may be observed on peripheral
blood smears and may lead to
spuriously elevated platelet counts.
They have been reported to disturb
the white blood cell (WBC)
differential count if they clumped
together, and a large number of such
microorganisms have been shown to
increase WBC counts.
Shaweta9, stated that in the
case of fungus ball, surgery is always
needed as a case management.
Currently, endoscopic sinus surgery
(ESS) has been performed as an
option. This is curative approach and
does not require local or systemic
antifungal therapy after the
5,9
procedure. The use of antifungal
can be given only in cases with the
invasion of the fungus to the bone.
There were no incidents of recurrence
of fungus ball in the nasal cavity after
9
therapeutic procedure according to
the literature.7
CONCLUSION
Fungus ball is an important
differential diagnosis for rhinolith or
foreign body in nasal cavity. CT scan
may be able to distinguish between
fungus ball and rhinolith in addition
to histopathology examination as a
gold standard. Endoscopic sinus
surgery (ESS) is the treatment of
choice for fungus ball in the nasal
cavity.
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