fungal infection of the paranasal sinuses with uncommon species is an increasingly recognized entity , both in normal and immunocompromised individuals . the pattern of fungal infection of the sinuses can be divided into invasive , noninvasive , and semi - invasive based on the presence of fungal hyphae in the tissue with associated granulomatous reaction or tissue necrosis [ table 1 ] . although fungal infections of the paranasal sinus are uncommon , 35% of cultured sinus samples are positive for fungi . aspergillus species are the most common causative agents of fungal sinusitis followed by candida and mucor . hyalohyphomycosis ( gk . hylos  glass ) is an infection caused by a number of species in which the basic tissue form of fungi is hyaline without any pigment in their cell wall . . the disease may present as cutaneous , subcutaneous or systemic infection in the immunocompetent or immunocompromised patients . this article presents a case report of maxillary sinus hyalohyphomycosis caused by two opportunistic soil saprophytes of paecilomyces and scopulariopsis species . a 40-year - old adult male reported to the outpatient department with the chief complaint of a firm mass in the left cheek region . the duration of the swelling was approximately 6 months and the growth was continuous , slow , and painless . the patient was a farmer by profession and had no history of illness . on further probing , the patient gave the history of decay and infection in the left maxillary second molar a year ago . he underwent an unwarranted and irregular course of antibiotics and other drugs for almost 23 months prescribed by traditional practitioners in his village followed by extraction . the swelling appeared on the left cheek after approximately 2 months of extraction . on examination , the swelling was firm , nontender , sessile , mobile and oval in shape . it measured 4  3 cm and was not fixed to the surrounding soft tissue . there was no paraesthesia over the distribution of infraorbital nerve and the overlying skin was unaffected . intraorally , the left maxillary teeth were vital on pulp testing with no periapical radiolucency in dental radiographs . an occipito - mental view ( omv ) of skull showed generalized opacification of the left maxillary sinus . the computerized tomography ( ct ) scan showed evidence of well - defined , homogeneously enhancing soft tissue mass lesion seen in the left maxillary sinus [ figures 1 and 2 ] . the lesion was causing lytic destruction of anterior wall of the sinus and also the erosion of left floor of orbit . routine hematological evaluation showed mild leucocytosis with eosinophilia and an increased erythrocyte sedimentation rate ( esr ) [ table 2 ] . a differential diagnosis of a chronic sinusitis , benign cyst or tumor , and maxillary antrum mycosis was made , and an incisional biopsy was performed under local anesthesia . the pathological tissue was creamish in color , firm in consistency , and hyalinized in texture [ figure 3 ] . hematological values of the patient pathological specimen the histopathological picture showed diffuse areas of fibrosis and granulation tissue with patchy infiltrate of acute and chronic inflammatory cells . there were few septate organisms , giant cells , macrophages , epitheloid cells , and foci of hemorrhage . microbiological studies included koh ( potassium hydroxide ) wet mount , lcb ( lactophenol cotton blue ) preparation , and culture on sabouraud 's dextrose agar ( sda ) . one thin and white at first and then became gray tan in color and second golden colored , fast growing and powdery . microscopic finding in the first culture showed chains of single - celled conidia produced in basipetal succession from annellide ( basocatenate ) . annellide were solitary with globose , truncate , smooth , and brown colored conidia [ figure 4 ] . microscopic finding of second colony showed conidiophores bearing dense , verticillately arranged branches bearing phialides . chlamydospores were present in short chains , brown , sub spherical and thick walled [ figure 5 ] . based on all these findings , the isolates were identified as paecilomyces and scopulariopsis species . pictomicrograph showing paecilomyces species ( koh 10  40 magnification ) having elongated and tapering phialides with ovoid conidia in basipetal succession pictomicrograph showing scopulariopsis species ( koh 10  40 magnification ) having basipetal globose to pyriform conidia on annellides ( solitary and in groups ) the patient was put on oral itraconazole 200 mg twice daily for a week which resulted in a significant reduction of the extraoral swelling . a thorough sinus debridement and lavage the sinus was approached by the standard caldwell - luc method because of the evident bony erosion of the anterior wall which had to be removed simultaneously [ figure 6 ] . a plastic drain was fixed oroantrally for irrigation after sinus clearance . in the postoperative phase , the patient was again put on oral itraconazole 200 mg twice daily and the sinus was irrigated with 1% acetic acid once daily for 7 days . the patient is been followed regularly for the last 1 year and a check omv x - ray of skull confirmed repneumatization of the left maxillary sinus with complete resolution of clinical sign and symptoms . on examination , the swelling was firm , nontender , sessile , mobile and oval in shape . it measured 4  3 cm and was not fixed to the surrounding soft tissue . there was no paraesthesia over the distribution of infraorbital nerve and the overlying skin was unaffected . intraorally , the left maxillary teeth were vital on pulp testing with no periapical radiolucency in dental radiographs . an occipito - mental view ( omv ) of skull showed generalized opacification of the left maxillary sinus . the computerized tomography ( ct ) scan showed evidence of well - defined , homogeneously enhancing soft tissue mass lesion seen in the left maxillary sinus [ figures 1 and 2 ] . the lesion was causing lytic destruction of anterior wall of the sinus and also the erosion of left floor of orbit . routine hematological evaluation showed mild leucocytosis with eosinophilia and an increased erythrocyte sedimentation rate ( esr ) [ table 2 ] . a differential diagnosis of a chronic sinusitis , benign cyst or tumor , and maxillary antrum mycosis was made , and an incisional biopsy was performed under local anesthesia . the pathological tissue was creamish in color , firm in consistency , and hyalinized in texture [ figure 3 ] . the histopathological picture showed diffuse areas of fibrosis and granulation tissue with patchy infiltrate of acute and chronic inflammatory cells . there were few septate organisms , giant cells , macrophages , epitheloid cells , and foci of hemorrhage . microbiological studies included koh ( potassium hydroxide ) wet mount , lcb ( lactophenol cotton blue ) preparation , and culture on sabouraud 's dextrose agar ( sda ) . one thin and white at first and then became gray tan in color and second golden colored , fast growing and powdery . microscopic finding in the first culture showed chains of single - celled conidia produced in basipetal succession from annellide ( basocatenate ) . annellide were solitary with globose , truncate , smooth , and brown colored conidia [ figure 4 ] . microscopic finding of second colony showed conidiophores bearing dense , verticillately arranged branches bearing phialides . chlamydospores were present in short chains , brown , sub spherical and thick walled [ figure 5 ] . based on all these findings , the isolates were identified as paecilomyces and scopulariopsis species . pictomicrograph showing paecilomyces species ( koh 10  40 magnification ) having elongated and tapering phialides with ovoid conidia in basipetal succession pictomicrograph showing scopulariopsis species ( koh 10  40 magnification ) having basipetal globose to pyriform conidia on annellides ( solitary and in groups ) the patient was put on oral itraconazole 200 mg twice daily for a week which resulted in a significant reduction of the extraoral swelling . a thorough sinus debridement and lavage the sinus was approached by the standard caldwell - luc method because of the evident bony erosion of the anterior wall which had to be removed simultaneously [ figure 6 ] . a plastic drain was fixed oroantrally for irrigation after sinus clearance . in the postoperative phase , the patient was again put on oral itraconazole 200 mg twice daily and the sinus was irrigated with 1% acetic acid once daily for 7 days . the patient is been followed regularly for the last 1 year and a check omv x - ray of skull confirmed repneumatization of the left maxillary sinus with complete resolution of clinical sign and symptoms . chronic indolent fungal sinusitis can occur in both immunocompetent and immunocompromised individual and was first described by hora in 1965 . it is mostly invasive and is characterized histologically by a chronic granulomatous inflammation surrounding broken fungal hyphae . this type of fungal sinusitis may extend beyond the bony confines of the sinuses to the orbit or even to the anterior cranial fossa . therefore , clinically it may mimic a malignant neoplasm , wegener 's granulomatosis , osteomylitis , tuberculosis , and rhinoscleroma . paranasal sinus mycoses are common in north india , northern sudan , and south - western states of the north america which have warm and humid climate . saprophytic fungi are ubiquitous and omnipresent in nature , mostly surviving on dead organic plant matter . some species survive as commensals within the body cavities of humans , including the nose and paranasal sinuses . when a favorable situation ( immunocompromised status ) arises as in prolonged steroid or antibiotic therapy or postsurgical exposure of raw areas , these dimorphic fungi metamorphosize into invasive forms and present themselves in a panoramic spectrum of clinical manifestations [ table 3 ] . an unwarranted and uncontrolled misuse of drugs , especially antibiotics , steroids , and antihistamines , in semi - urban and rural population is an important factor to contribute to this disease in developing countries such as india . the maxillary and ethmoid sinuses are more commonly involved because drainage depends on mucocilliary propagation in these sites . criteria for sinonasal fungal infection during the recent decades , paranasal sinus mycosis has been recognized more frequently in different parts of the world mainly because of the following reasons : ( 1 ) increased awareness among clinicians ; ( 2 ) improved diagnostic tools ; and ( 3 ) increased host susceptibility . successful treatment of such indolent mycotic infections largely depends on the accurate identification of the pathogen and early , appropriate intervention by surgical debridement and sinus ventilation , supported with antifungal medications as per standardized regimen .
fungal infection of the paranasal sinuses is an increasingly recognized entity , both in normal and immunocompromised individuals . 
 the recent increase in mycotic nasal and paranasal infections is due to both improved diagnostic research and an increase in the conditions that favor fungal infection . 
 although fungal infections of the paranasal sinus are uncommon , 35% of incidence is reported . 
 aspergillus , candida , and mucor species are the most common causative agents of fungal sinusitis , but infection with lesser known species have been reported across the world infrequently . 
 this article reviews and presents a case report of chronic fungal sinusitis in an immunocompetent adult male infected with two species of hyalohyphomycosis group namely , paecilomyces and scopulariopsis which are opportunistic soil saprophytes , uncommon to humans .