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British Journal of Oral and Maxillofacial Surgery 47 (2009) 313–315

Short communication
Aspergillosis of the maxillary sinus secondary to a foreign
body (amalgam) in the maxillary antrum
Richard Burnham a,∗ , Chris Bridle b,1
a Oral and Maxillofacial Surgery Centre, The Royal London Hospital, First Floor, John Harrison House, Philpot Street,
Whitechapel, London, E1 1BB, United Kingdom
b Oral and Maxillofacial Surgery Centre, The Royal London Hospital, London, E1 1BB, United Kingdom

Accepted 21 January 2009

Available online 28 February 2009

Abstract

We report a case of a Maxillary sinus aspergilloma, which presented after 2 years of symptoms of chronic sinusitis. There was an isolatable
triggering event of extrusion of an amalgam filling material into the sinus. This was a complication of surgical extraction of the upper right
second molar by his general dental practitioner.
© 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Aspergillosis; Maxillary antrum; Foreign body

Introduction all. This chronic caseous sinusitis is resistant to treatment

Aspergillosis is an infection caused by a dimorphic fungus of
the Aspergillus family, and humans are infected by inhalation
of spores. The disease includes an allergic bronchial reac-
tion, an aspergilloma, and an invasive aspergillosis, which is
more common in immunosuppressed patients and presents as
multiorgan disease.1
The maxillary antrum is a relatively common site for for-
mation of an aspergilloma where it forms around a nexus of
foreign body.2 Previous publications have indicated that any
dental material containing zinc that has been extruded into
the maxillary antrum has the potential to become infected
and form an aspergilloma. Root canal cements and amal-
gam contain zinc in large enough quantities to cause this
reaction.3
Patients with aspergillus sinusitis may report symptoms
of vague chronic sinusitis, or present with no symptoms at
∗
Corresponding author. Tel.: +44 207 3777000.
E-mail addresses: richardb980@aol.com (R. Burnham),
chris.bridle@bartsandthelondon.nhs.uk (C. Bridle).
1 Tel.: +44 207 3777000.
with first line drugs, and often requires debridement of the
antrum.4
Case report
A 46-year-old Bengali man was referred to the Department of
Oral and Maxillofacial Surgery by his dentist. He complained
of paraethesiae of the maxillary teeth, and right maxillary
pain that was aggravated by changes in posture. He had no
nasal blockage, discharge, or postnasal drip.
The pain had started 2 years previously, after extraction
of a heavily restored and infected upper right second molar
by his dentist. This was complicated postoperatively by a
severe localised alveolar osteitis, but no signs of an oroantral
communication.
On examination there were no gross abnormalities. The
upper right second molar ridge had fully healed with no
sign of an oroantral fistula. A plain occipitomental radio-
graph showed an opacity of the right maxillary antrum with
a central radio-opacity. Computed tomograms (CT) of his
maxillary sinus confirmed considerable mucosal thickening

0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2009.01.015
314 R. Burnham, C. Bridle / British Journal of Oral and Maxillofacial Surgery 47 (2009) 313–315
Fig. 1. Sagittal view of the right maxillary antrum through the line of the
upper right first and third molars showing a hyperdense focus of amalgam
on the aspillagoma.
arising from the antral floor with an irregular focus of hyper-
dense material (Figs. 1 and 2).
He was treated by functional endoscopic clearance of the
sinus as a day case, which at the time showed that the mate-
rial was a portion of amalgam filling (Fig. 3). Histological
examination of the surrounding tissue showed large collec-
tions of aspergillus arranged in the form of an onion-skin-like
structure. The features were in keeping with an aspergilloma
secondary to a foreign body.
The patient made an uneventful recovery. He will require
review at 6 months to ensure complete resolution of
the aspergilloma. No further treatment is required at this
stage.
Fig. 2. Coronal view of the right maxillary antrum showing a hyperdense
focus of amalgam in the aspillagoma.
Fig. 3. Intraoperative endoscopic picture showing the Black’s class II-
shaped piece of amalgam at the superior aspect of the picture.
Discussion
This case highlights the importance of inclusion of
aspergilloma infections when patients present with an asymp-
tomatic radio-opacity of one maxillary sinus. It is a useful
illustration of a less common disease in the head and neck
region, of which all clinicians working in this area should be
aware.
Our understanding of fungal infections has changed,
as has the management of such conditions. Signs of
fungal infection vary from allergic sinusitis and fungal
masses to invasive fungal sinusitis as part of a wider
spectrum of disease. Aspergilloma of the facial sinuses
is usually associated with some predisposing factor be it
immunosuppression, local tissue hypoxia, or massive fungal
inoculation.
Aspergillomas may be treated with a traditional Caldwell-
Luc operation or by the newer functional endoscopic
techniques. The outcome with either is good and there is
rarely a need for systemic antifungal substances such as
amphotericin B, unless there is invasive disease or the patient
is immunosuppressed.5
The disease is probably preventable if dental mate-
rial has become the nexus for infection. The case shows
the need for careful postoperative inspection and debride-
ment of sockets by dentists to prevent foreign bodies
entering the maxillary sinus or soft tissues, the compli-
cations of which include mucosal tattoos, foreign body
reactions, and infections, which can lead to formation of an
aspergilloma.
References
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and differentiation of the pathogenesis based on computed tomogra-
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