Case report
63-year-old immunocompetent man, with no comorbidities, has as main complaint pain, in the forehead, predominantly left, with a stabbing character, starting two months ago, with no evolution. During this period, he used antibiotics, anti-inflammatories, and topical and systemic corticosteroids, with no improvement in his condition.
The initial hypotheses that guide the request for the first exams were nasal tumors, recurrent acute and chronic rhinosinusitis.No abnormalities in blood and serological tests. The endoscopic examination of the nasal cavity revealed mucosal edema with purulent secretion of the ostiomeatal complex. CT scan of the paranasal sinuses identified veiling of the frontal sinus with microcalcifications, hyper-attenuating areas, associated with bone wall sclerosis, suggestive of fungal bolus (Figures 2 and 3). As these CT findings are typical of a fungal ball, there were no differential diagnoses.
The patient underwent maxillary sinusectomy, wide ethmoidectomy and frontal sinusectomy like DrafIIa, with complete removal of the lesion (Figure 4). The microbiological examination showed sparse fragments of mucosa covered by respiratory epithelium, with edema of the lamina propria and a marked inflammatory infiltrate (lymphocytes, neutrophils, histiocytes and plasma cells). Abundant septate fungal hyphae were dichotomized at an acute angle, compatible with Aspergillus sp ., with no signs of malignancy in the present material and the search for fungi by Grocott stain was positive. Biopsy of the healthy frontal sinus mucosa confirmed negative non-invasive fungal ball.
There were no intraoperative and postoperative complications. Currently, the patient has an 8-month follow-up and complete improvement of the condition.