Surgical treatment of Aspergillus mycetomas of the maxillary

sinus: Review of the literature

Fabio Costa, MD,a Francesco Polini, MD,a Nicoletta Zerman, MD,b
Massimo Robiony, MD, FEBOMS,c Corrado Toro, MD,d and Massimo Politi, MD, DMD,e
Udine and Ferrara, Italy
UNIVERSITY OF UDINE AND UNIVERSITY OF FERRARA

The present study reviews the literature concerning the surgical treatment of Aspergillus mycetoma (AM)
in the last 20 years to identify a gold standard surgical technique. Aspergillus mycetoma of the maxillary sinus, or
mycetoma (fungus ball), is a noninvasive or extramucosal mycotic infection. Surgical removal of the sinus fungal
masses to ensure drainage and aeration is performed using the traditional Caldwell-Luc (CL) procedure or endoscopic
sinus surgery (ESS). Results of this review suggest that the gold standard surgical technique for AM is ESS with middle
meatal antrostomy. General or local antifungal drugs are not indicated. Combined approach with an intraoral surgical
access from the anterolateral wall of the maxillary sinus has to be reserved for selected cases in which ESS doesn’t
permit complete extraction of all fungal concretions or foreign bodies. The CL procedure should be avoided, because it
has detrimental consequences for sinus physiology. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:
e23-e29)

The recent rise in mycotic nasal and paranasal infec-
tions is due to both improved diagnostic research and
an increase of the conditions that favor fungal infec-
tions.1-3 Improvement of the diagnostic research in-
volves the use of computerized tomography (CT) in-
stead of conventional radiograph to investigate
paranasal sinuses. Conditions that favor fungal infec-
tions are diabetes, long-term treatments (antibiotics and
cortisones), radio- and chemotherapy, immunosuppres-
sive treatments, and immunodeficient disease.4 Many
authors suggest that mycotic infections of the paranasal
cavity are found more commonly in apparently healthy
patients. The most frequent microorganism involved in
Europe is Aspergillus fumigatus.5
a
Assistant Professor of Maxillofacial Surgery, Department of Maxil-
lofacial Surgery, Azienda Ospedaliero Universitaria, Faculty of Med-
icine, University of Udine.
b
Associate Professor of Oral Pathology, Faculty of Medicine, Uni-
versity of Ferrara.
c
Associate Professor of Maxillofacial Surgery, Department of Max-
illofacial Surgery, Azienda Ospedaliero Universitaria, Faculty of
Medicine, University of Udine.
d
Resident in Maxillofacial Surgery, Department of Maxillofacial
Surgery, Azienda Ospedaliero Universitaria, Faculty of Medicine,
University of Udine.
e
Dean of Medicine and Professor of Maxillofacial Surgery, Head of
Department of Maxillofacial Surgery, Azienda Ospedaliero Univer-
sitaria, Faculty of Medicine, University of Udine.
Received for publication Oct 13, 2006; returned for revision Nov 17,
2006; accepted for publication Dec 15, 2006.
1079-2104/$ - see front matter
© 2007 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2006.12.015
Aspergillus mycetoma (AM) of the maxillary sinus –
aspergilloma or mycetoma (fungus ball) – is a nonin-
vasive or extramucosal mycotic infection. It mostly
affects immunocompetent patients, almost exclusively
adults, and is characterized by a female predominance.
The etiopathogenesis of AM has been debated, and
there have been 3 theories: odontogenic, aerogenic, and
mixed origins.6
The odontogenic school of thought maintains that the
pathogenesis is based on an initial colonization of the
maxillary sinus by means of iatrogenic oral-antral com-
munication. This theory holds that the zinc oxide which
can be found in endodontic sealers paralyzes the epi-
thelial cilia or causes edema and hyperemia of the soft
tissues, affecting the Schneiderian (sinus membrane)
epithelium function. This favors the accumulation of
fungal waste and impairs elimination of the spores. The
aerogenic theory suggests that Aspergillus growth is
due to inhalation of high quantities of spores over
extended periods. This form of fungal sinusitis has been
reported primarily in Sudan, is granulomatous in na-
ture, and is almost always associated to Aspergillus
flavus infection. It is also called semi-invasive form of
fungal sinusitis, according to varying degrees of dis-
ruption of normal sinus bony architecture observed on
CT scans.7 The third theory is based on the ubiquitous
nature of the Aspergillus spores. They can be inhaled at
any moment and are normally present as saprophytes in
the maxillary sinus. Aspergillus growth can be due to
poorly ventilated sinus, a pre-existing sinusitis, or for-
eign bodies in the sinus. For the ostium to be ventilated
and drained, it must be unobstructed. If the ostium is

e23

e24 Costa et al.
blocked, the mucociliar clearance system is negatively
influenced and Aspergillus growth is favored.
Several clinical presentations have been reported,
from acute infection to an asymptomatic form.8-9 Nev-
ertheless, the most frequent clinical presentation is not
specific, with various symptoms such as nasal obstruc-
tion, purulent nasal discharge, facial pain, and chronic
cough. Endoscopic examination is most often normal,
but edema and purulent secretions may be observed.
Often for asymptomatic forms the diagnosis is made
after an occasional orthopantomography performed
during routine dental treatment (Fig. 1).
The characteristic CT scan presentation includes typ-
ically heterogeneous opacities associated with a metal
dense spot in the involved maxillary sinus (Fig. 2).10-11
Diagnosis is made after histologic examination, be-
cause cultural exams are often negative.5,8
With respect to the treatment of AM, it is necessary
to remove surgically the sinus fungal masses and ensure
the establishment of adequate sinus drainage and aera-
tion via the Caldwell-Luc (CL) procedure12-13 or endo-
scopic sinus surgery (ESS).9,14
We reviewed the literature concerning the surgical
treatment of maxillary aspergilloma in the last 10 years
to verify which is the actual best surgical treatment.
REVIEW OF THE LITERATURE
Aspergillus mycetoma of the maxillary sinus may be
found in immunocompetent patients with 2 different clin-
ical features: symptomatic and asymptomatic. Symptom-
atic patients have classic symptoms of chronic sinusitis
with nasal secretions, pain, and sometimes zygomatic
swellings. Asymptomatic patients have diagnosis after
routine radiographic examinations.
Certain conditions may change the normal ecosys-
tem to allow fungal proliferation. The most common of
these favorable conditions are prolonged antibiotic and
corticosteroid treatments, nasal obstructions that aid
blockage of the ostium and anaerobic conditions, and
endosinal penetrations at the time of a dental procedure,
such as root canal perforation, a canal overfilling, or a
dental extraction.
Even if the therapeutic strategies for treating AM are
mainly surgical and ESS is nowadays the favorite ap-
proach, it is surprising that CL has continued to be
performed even recently.8,12-13 This procedure, de-
scribed in 1893 by George Walter Caldwell, provides
an enlarged canina fossa opening to obtain access to the
maxillary antrum and a complete removal of the sinus
mucosa. The procedure was combined with an inferior
or middle meatus antrostomy that facilitated gravita-
tional drainage of secretions. The same technique was
described independently by Henri-Paul Luc in 1897.15
The CL procedure remained one of the most used
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June 2007
techniques in modern rhinology until the advent of
ESS.
Patients treated with CL for chronic and recurrent
maxillary sinusitis have a higher complication rate than
patients treated with ESS.16 In a comparative study of
Penttila et al.,17 patients’ global evaluation was dem-
onstrated to be superior after ESS compared with CL.
Overall patients’ compliance, asked postoperatively,
was 80.2% in CL patients and 93.0% in ESS patients.
The CT and endoscopic appearance of the sinus after
ESS is superior compared with CL.18 Fibrosis and
abnormal bony changes of the maxillary sinus were
encountered in more than half of CL cases.
Inferior meatal antrostomy, as performed during CL,
seems to be useless, because analysis of ciliary flow
patterns in rabbits revealed that the nasal antral window
did not cause redirection of the mucociliary clearance
pattern19 and that the cilia in the sinus continue to clear
mucus toward the natural ostium despite surgical
alteration.20
For these reasons, the CL procedure is no longer the
surgical treatment of choice and is only indicated by
some authors9,21 as a complementary step when the
complete removal of the fungal ball is impossible
through a middle meatal antrostomy approach alone.
In the present review we found 262 cases of maxil-
lary AM in the last 10 years (Table I). The studies
reviewed confirm that ESS is the treatment of choice,
with a higher prevalence of this surgical treatment (236
cases, 90%) against the traditional CL approach (26
cases, 10%).
Only 6 studies with a consistent sample of patients
have been published. Even if ESS can be considered to
be the treatment of choice, there are 1 of the 6 studies
with a consistent sample8 and many case reports, even
recently published,13,24-25 in which treatment of max-
illary aspergilloma was performed with the traditional
CL. Ferreiro et al.,8 who reported the most consistent
sample of patients treated with the CL, justified this
surgical approach with the fact that recurrence has not
been documented after this procedure, whereas the re-
currence rate after endoscopic techniques is 6.8%. Re-
sults of the present review revealed a recurrence rate
after ESS lower than that reported by Ferreiro et al. (3%
vs. 6.8%).
A recent experimental study by Dufour et al.30 seems
to emphasize the importance of ESS for the treatment
of AM. They divided 34 rabbits into 3 groups. In the
first group (10 rabbits), A. fumigatus was inoculated
into the maxillary sinus. In the second group (10 rab-
bits), A. fumigatus was inoculated into the maxillary
sinus in the presence of a wound in the mucosa. In the
third group (14 rabbits), A. fumigatus was inoculated
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Volume 103, Number 6
Fig. 1. Orthopantomography of a patient with AM performed during routine dental treatment.
Fig. 2. Computerized tomography scan presentation of the same patient in Fig. 1.
into the maxillary sinus in the presence of a blocked
ostium. They found that noninvasive fungal sinusitis
had been induced in 2 rabbits of the second group and
8 rabbits of the third group. They concluded that intro-
duction of fungi into a sinus with a blocked ostium
induces fungal sinusitis. The traditional CL procedure
does not affect the maxillary natural ostium, which
seems to be important in the development of AM.
The aim of ESS, which has replaced traditional CL,
is to open the natural ostium of the sinus involved to
restore drainage and ventilation. Debridement of the
polypoid mucosa, if present, in the middle meatus can
be performed, and a wide antrostomy may be created
by removing most of the posterior fontanelle and con-
necting a possible secondary maxillary ostium to the
area of the maxillary natural ostium anteriorly. From
the middle meatus antrostomy, sinus lavages may be
performed using an angled aspirator to facilitate endo-
nasal discharge of the mycotic concretions of the sinus
(Fig. 3). The advantages of this method are that the
Costa et al. e25
trauma to the patient is less than that derived from
external procedures, and ventilation and drainage are
re-established through the natural ostia31 (Fig. 4). En-
doscopic sinus surgery with a middle meatus antros-
tomy presents only 1 technical problem for the treat-
ment of maxillary AM. It does not allow visualization
of the angle formed by the bony lacrimal duct and the
anterior maxillary sinus wall (lacrimal recess of the
maxillary sinus). Permanence of mycotic concretions at
this level has been suggested as a possible cause for
recurrence.22 However, in cases of difficult removal of
mycotic concretions it is possible to complete the re-
moval by a trocar in the canine fossa,9 the so-called
double approach.27
Endoscopic sinus surgery with middle meatus antr-
ostomy, with or without a canine fossa approach, is the
treatment of choice in 4 of the 6 studies reviewed with
a more consistent sample of patients,9,14,26,27 but the
most recent study by Dufour et al.14 is an integration of
a previous sample.9 Double approach was performed in
 OOOOE
e26 Costa et al. June 2007

Table I. Surgical treatment of maxillary sinus aspergilloma (1995-2006)

Recurrence
Authors and institute Year No. patients ESS after ESS Caldwell Luc Comment
Dufour et al.14 2005 56 (plus 94 56 1 — Surgical treatment of a fungus ball
Department of Otolaryngology cases consists in opening the infected
and Head and Neck Surgery, previously sinus cavity at the level of its
Poitiers, France published) ostium and removing fungal
concretions while sparing the
normal mucosa. No antifungal
therapy is required. FESS
appears to be a reliable and safe
surgical treatment with low
morbidity.
Chobillon and Jankowski22 2004 19 Group A: 10 ESS; — — The endoscopic canine fossa
Department of Otolaryngology group B: 9 ESS approach offers several
and Head and Neck Surgery, ⫹ endoscopic advantages over other
Nancy, France canine fossa techniques.
approach; group
C: endoscopic
canine fossa
approach
Chao23 2004 1 1 — — Case report
Department of Otolaryngology,
Taipei, Taiwan
Martins and Ribeiro Rosa13 2004 1 — — 1 Case report
University of Panama, Curitiba,
Brazil
Shams and Motamedi24 2003 1 — — 1 Case report
Department of Oral and
Maxillofacial Surgery,
Tehran, Iran
Khongkhunthian and Reichart25 2001 2 — — 2 Case report
Department of Restorative
Dentistry, Chiang Mai,
Thailand
Castelnuovo et al.26 2000 24 24 2 — ESS appears to be a reliable and
Clinica otorinolaringoiatrica, safe surgical treatment for
Pavia, Italia paranasal sinus mycoses.
Feng et al.27 2000 41 41 — — FESS is effective in the treatment
Department of of noninvasive aspergillosis of
Otorhinolaryngology, the maxillary sinus. The double
Nanjing, China pathway operation is superior to
the single pathway. Using
antifungal drugs to wash the
operative cavity has no obvious
effect on efficacy.
Ferreiro et al.8 1997 20 1 — 13 Caldwell Maxillary aspergilloma may be
Department of Head and Neck Luc ⫹ 6 treated with ESS or with a
Surgery, Mayo Clinic, nasoantral Caldwell-Luc procedure.
Rochester, Minnesota window
Klossek et al.9 1997 94 94 4 — FESS was performed in all cases.
Department of Otolaryngology In the postoperative period, no
and Head and Neck Surgery, medical treatment is prescribed.
Poitiers, France This study reinforces the
interest in FESS for cases of
mycetoma of the paranasal
sinuses.
Ogata I et al.28 1997 1 — — 1 Case report
Department of Otolaryngology,
Yamaguchi, Japan
Falworth and Herold12 1996 1 — — 1 Case report
Department of Oral and
Maxillofacial Surgery, Royal
Surrey County, England
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Volume 103, Number 6
Table I. Continued
Authors and institute Year No. patients ESS
Kobayashi29 1995 1 —
Department of Oral Surgery,
Saitama, Japan
Total 262 236 (90%)
ESS, endoscopic sinus surgery; FESS, functional endoscopic sinus surgery.
Fig. 3. Removal of the mycotic concretions from the middle
meatus after sinus lavages from the antrostomy.
97 of 150 procedures (65%) by Dufour et al.14 Feng
et al.27 observed that the period of convalescence of
double pathway surgery (via ostium of maxillary sinus
and canine fossa) was 4.7 weeks, whereas single path-
way (via ostium of maxillary sinus only) was 9.3
weeks. They asserted that the double pathway operation
is superior to the single pathway. There is a general
agreement that ESS is effective in treating aspergilloma
of the maxillary sinus and that general or local antifun-
gal drugs are not indicated.14,27
The last of the 6 studies with a consistent sample of
patients retrospectively analyzed the results of the sur-
gical treatment of 31 patients presenting maxillary
AM.22 Patients were divided into 3 groups. Group A
included 10 patients operated on with an endonasal
middle meatotomy only, group B included 9 patients
who were operated on using a combined approach
(endonasal middle meatus antrostomy and endoscopic
Costa et al. e27
Recurrence
after ESS Caldwell Luc Comment
— 1 Case report
7 (3%) 26 (10%)
Fig. 4. Postoperative endoscopic view one year after middle
meatus antrostomy showing maintenance of opening and the
absence of discharge from the sinus.
canine fossa approach), and group C included 12 pa-
tients who were operated on using an endoscopic ca-
nine fossa approach alone. No recurrences were noted
in any group, but in group B 3 patients presented mild
complications, such as persistent purulent discharge
through the meatotomy and nasal crusting. The authors
concluded that the endoscopic canine fossa approach of-
fers several advantages over other techniques: an optimal
visualization of all maxillary sinus walls; the possibility of
performing the procedure under local anesthesia; the pres-
ervation of the anatomy and physiology of the natural
maxillary ostium, and an easy removal of any foreign
bodies of dental origin in the sinusal cavity which could
favor the development of AM.
The first observation regarding this study is the short
follow-up of the sample, which is of at most 6 months.
Concerning the preservation of the natural maxillary
ostium, we may observe that it cannot be considered an

e28 Costa et al.
advantage. The experimental study by Dufour et al.30
emphasizes the role of a blocked ostium in the patho-
genesis of the development of AM, and the endoscopic
canine fossa approach does not correct an obstruction
that could be present at the level of the ostium. This
was confirmed in a study by Castelnuovo et al.,26 in
which 3 patients with recurrence of AM after ESS
presented a postoperative scar with a consequent ste-
notic ostium.
The endoscopic canine fossa approach has also pre-
sented some disadvantages, emphasized by Chobillon
and Jankowski.22 These include the impossibility of
performing a direct control of the maxillary sinus in the
postoperative follow-up, the impossibility of perform-
ing a postoperative lavage of the sinusal cavity, and the
impossibility performing the procedure in children until
it is certain that full dentition is complete. Another
disadvantage of this technique and of the canine fossa
approach in general which has not been reported by any
of the studies reviewed is the postoperative scar in the
canine anterior wall of the maxillary sinus. We have to
consider that patients with aspergilloma are often an
elderly population and may present extraction gaps;
therefore, a future bone reconstruction with a sinus
graft may be required for prosthetic rehabilitation. The
site of the canine fossa approach is approximately the
same as that necessary for a prospective sinus bone graft.
Creation of the bone window and elevation of the sinus
membrane to allow insertion of the graft material to
perform sinus bone graft could be technically more
difficult or impossible because of the residual scar.
Chobillon and Jankowski22 emphasized that the win-
dow created in the anterior maxillary sinus wall is as
small as possible, allowing just the passage of a 4-mm
rigid endoscope and a forceps or an aspirator. There-
fore, we may optimistically presume that a window of
at least 7 mm diameter could interfere with a future
bone graft.
For this reason, we suggest that intraoral surgical
access to the maxillary sinus for AM has to be per-
formed only when really useful for the removal of
mycotic concretions and not as a standard procedure.
In conclusion, results of the present review suggest
that ESS with middle meatal antrostomy is the gold
standard surgical procedure to manage maxillary AM.
General or local antifungal drugs are not indicated.
Combined approach with intraoral surgical access from
the anterolateral wall of the maxillary sinus has to be
reserved for selected cases in which ESS does not
permit complete extraction of all fungal concretions or
foreign bodies. The traditional CL procedure should be
avoided because of its detrimental consequences for
sinus physiology.
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June 2007
REFERENCES
1. Beck-Mannagetta J, Necek D. Radiologic findings in aspergillo-
sis of the maxillary sinus. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1986;62:345-9.
2. Krennmair G, Lenglinger F. Maxillary sinus aspergillosis: diag-
nosis and differentiation of the pathogenesis based on computed
tomography densitometry of sinus concretions. J Oral Maxillofac
Surg 1995;53:657– 6.
3. Stammberger H, Jakse R, Beaufort F. Aspergillosis of the para-
nasal sinuses x-ray diagnosis, histopathology, and clinical as-
pects. Ann Otol Rhinol Laryngol 1984;93:251-6.
4. De Foer C, Fossion E, Vaillant JMJ. Sinus aspergillosis. Crani-
omaxillofac Surg 1990;18:33-40.
5. deShazo RD, Chapin K, Swain RE. Fungal sinusitis. N Engl
J Med 1997;337:254-9.
6. Bertrand B, Rombaux P, Eloy P, Reychler H. Sinusitis of dental
origin. Acta Otorhinolaryngol Belg 1997;51:315-22.
7. deShazo RD, O’Brien M, Chapin K, Soto-Aguilar M, Swain R,
Lyons M, et al. Criteria for the diagnosis of sinus mycetoma.
J Allergy Clin Immunol 1997;99:475-85.
8. Ferreiro JA, Carlson BA, Cody DT 3rd. Paranasal sinus fungus
balls. Head Neck 1997;19:481-6.
9. Klossek JM, Serrano E, Peloquin L, Percodani J, Fontanel JP,
Pessey JJ. Functional endoscopic sinus surgery and 109 myce-
tomas of paranasal sinuses. Laryngoscope 1997;107:112-7.
10. Dhong HJ, Jung JY, Park JH. Am J. Diagnostic accuracy in sinus
fungus balls: CT scan and operative findings. Rhinology 2000;
14:227-31.
11. Ferguson BJ. Fungus balls of the paranasal sinuses. Otolaryngol
Clin North Am 2000;33:389-98.
12. Falworth MS, Herold J. Aspergillosis of the paranasal sinuses. A
case report and radiographic review. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1996;81:255-60.
13. Martins WD, Ribeiro Rosa EA. Aspergillosis of the maxillary
sinus: review and case report. Scand J Infect Dis 2004;
36:758-61.
14. Dufour X, Kauffmann-Lacroix C, Ferrie JC, Goujon JM, Rodier
MH, Karkas A, Klossek JM. Paranasal sinus fungus ball and
surgery: a review of 175 cases. Rhinology 2005;43:34-9.
15. Tange RA. Some historical aspects of the surgical treatment of
the infected maxillary sinus. Rhinology 1991;29:155-62.
16. Narkio-Makela M, Qvarnberg Y. Endoscopic sinus surgery or
Caldwell-Luc operation in the treatment of chronic and recurrent
maxillary sinusitis. Acta Otolaryngol Suppl 1997;529:177-80.
17. Penttila MA, Rautiainen ME, Pukander JS, Karma PH. Endo-
scopic versus Caldwell-Luc approach in chronic maxillary sinus-
itis: comparison of symptoms at one-year follow-up. Rhinology
1994;32:161-5.
18. Unlu HH, Caylan R, Nalca Y, Akyar S. An endoscopic and
tomographic evaluation of patients with sinusitis after endo-
scopic sinus surgery and Caldwell-Luc operation: a comparative
study. J Otolaryngol 1994;23:197-203.
19. Kennedy DW, Shaalan H. Reevaluation of maxillary sinus sur-
gery: Experimental study in rabbits. Ann Otol Rhinol Laryngol
1989;98:901-6.
20. Coleman JR Jr, Duncavage JA. Extended middle meatal antros-
tomy: the treatment of circular flow. Laryngoscope 1996;106:
1214-7.
21. Kennedy DW, Zinreich SJ, Rosenbaum AE, Johns ME. Func-
tional endoscopic sinus surgery. Theory and diagnostic evalua-
tion. Arch Otolaryngol 1985;111:576-82.
22. Chobillon MA, Jankowski R. What are the advantages of the
endoscopic canine fossa approach in treating maxillary sinus
aspergillomas? Rhinology 2004;42:230-5.
OOOOE
Volume 103, Number 6
23. Chao TK. Triple discrete fungus balls of the paranasal sinuses.
Otolaryngol Head Neck Surg 2004;131:1014-5.
24. Shams MG, Motamedi MH. Aspergilloma of the maxillary sinus
complicating an oroantral fistula. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2003;96:3-5.
25. Khongkhunthian P, Reichart PA. Aspergillosis of the maxillary
sinus as a complication of overfilling root canal material into the
sinus: report of two cases. J Endod 2001;27:476-8.
26. Castelnuovo P, Gera R, Di Giulio G, Canevari FR, Benazzo M,
Emanuelli E, et al. Paranasal sinus mycoses. Acta Otorhinolar-
yngol Ital 2000;20:6-15.
27. Feng LR, Tan CQ, Guo QM. Treatment of noninvasive aspergil-
losis of maxillary sinus by functional endoscopic sinus surgery.
Lin Chuang Er Bi Yan Hou Ke Za Zhi 2000;14:554-5.
28. Ogata Y, Okinaka Y, Takahashi M. Antrolith associated with
aspergillosis of the maxillary sinus: report of a case. J Oral
Maxillofac Surg 1997;55:1339-41.
Costa et al. e29
29. Kobayashi A. Asymptomatic aspergillosis of the maxillary sinus
associated with foreign body of endodontic origin. Report of a
case. Int J Oral Maxillofac Surg 1995;24:243-4.
30. Dufour X, Kauffmann-Lacroix C, Goujon JM, Grollier G, Rodier
MH, Klossek JM. Experimental model of fungal sinusitis: a pilot
study in rabbits. Ann Otol Rhinol Laryngol 2005;114:167-72.
31. Stammberger H. Endoscopic surgery for mycotic and chronic re-
curring sinusitis. Ann Otol Rhinol Laryngol Suppl 1985;119:1-11.
Reprint requests:
Dr. F. Costa
Clinica di Chirurgia Maxillo-Facciale
Azienda Ospedaliero Universitaria
P.le S. Maria della Misericordia
33100 Udine
Italy
maxil2@med.uniud.it