aspergillus is a ubiquitous fungus and belongs to the ascomycete molds , which together with penicillium form the family of aspergillaceae . they are commonly found in humid areas , damp soil or agricultural environment , on grain , cereal , moldy flour , and organic decaying or decomposing matter . the former or conidium , 13 m in diameter , is carried by air and easily inhaled in the lungs . the branching hyphae are 25 m in diameter , split dichotomously at 45 angle , and are best recognized by methanamine silver stain . spores are ubiquitous , usually introduced by inhalation , and are frequent inhabitants of the human upper respiratory tract . an infection commonly isolated in the lungs of immunocompromised patients and occasionally as a destructive lesion of the maxillary sinuses , anterior palate , and nasal passages is the result of the inhalation of spores of aspergillosis fumigates and aspergillosis flavus . a number of studies and experiences emphasize that aspergillosis of the paranasal sinuses also develops in people who are otherwise healthy . aspergillus sinusitis occurs in normal hosts but invasive and fulminant types are common in immunocompromised patients . the purpose of this paper is to draw attention to the clinical presentation , radiographic investigations , review of literature , and to emphasize the need for high index of suspicion in its histopathological diagnosis of this condition in maxillofacial region . a 70-year - old male patient presented with a chief complaint of slow growing swelling on left side of the face since 6 months.patient used to consume alcohol occasionally and was also hypertensive , for which he was receiving medication . dental history revealed extraction of left maxillary cuspid area 6 months back and then he noticed a nonhealing lesion in the same area . on inspection , extra - oral examination revealed a diffuse swelling that was present on the left side of the face involving the periorbital region and left maxillary region with slight edema of upper lip , with a deviation of face to the right side , from ala of the nose to the tragus anteroposteriorly , measuring around 34 cm . no scar or redness , but mild hyper pigmentation of left maxillary region was seen . decreased vision on left side with diplopia was observed in the patient [ figure 1 ] . extra - oral photograph showing swelling on left side of face intraorally , small papillomatous mass was found . on palpation , apart from confirming the above findings , firm and nontender swelling was observed on left maxillary region . temperature was not raised .  step deformity  with firm zygomatic bone over the infra orbital region was noted . computed tomography ( ct ) scan shows abnormal hypodense soft tissue in the left buccal and premaxillary spaces extending into the left buccal pad . abnormal soft tissue with air pockets that is seen in left maxillary antrum widening the left osteomeatal unit , extending into the left half of the nasal cavity , left frontal sinus through the frontoethmoid recess . there was an erosion of the alveolar cortex of the maxilla in the region of the central incisors , posterolateral wall of the left maxillary sinus , and inferior orbital wall ( orbital floor ) with extension of the soft tissue within the maxillary sinus , contiguous with the left buccal space and mild extension into the left orbital cavity with associated retrobulbar fat stranding [ figure 2 ] . ct pns showing there is erosion of alveolar cortex of the maxilla in the region of maxillary central incisors , posterolateral wall of the left maxillary sinus and inferior orbital wall ( orbital floor ) with extension of the soft tissue within the maxillary sinus , contiguous with buccal space and mild extension into orbital cavity on performing the caldwell - luc surgery , the surgical exploration showed a considerable amount of greenish - black necrotic debris filling the sinus , which was cleared , and the specimen was sent for histopathological examination . excisional biopsy was taken from left maxillary region . the specimen obtained for histopathological examination consisted of necrotic tissue and mucosa from margin of lesion . on gross anatomical finding , multiple soft tissues were received that were irregular in shape , cheesy in consistency , and brownish - black in color . examination of hematoxylin and eosin - stained sections revealed a pseudostratified ciliated columnar epithelium about 34 cell layer in thickness . photomicrograph reveals characteristic septate fungal hyphae of an aspergillus species ( h and e , 100 ) photomicrograph reveals fungal hyphae and a fruiting body of an aspergillus species ( h and e , 40 ) photomicrograph reveals fruiting body of an aspergillus species ( h and e , 100 ) further staining with methanamine silver stain showed septate dichomatous branching hyphae , and spores suggestive of aspergillus fungus [ figures 6 and 7 ] . photomicrograph reveals characteristic septate fungal hyphae of an aspergillus species ( gnott - gomori methanamine silver stain , 100 ) photomicrograph reveals spores of fungal hyphae of an aspergillus species ( gnott - gomori methanamine silver stain , 100 ) after reviewing clinical , radiographic , and histopathological findings , diagnosis of chronic invasive aspergillosis of paranasal sinuses was made . since its first description as an opportunistic infection in 1953 , there has been a substantial increase in the number of cases documented at autopsy in all developed nations . furthermore , there has been a substantial increase in the number of patients at the risk of developing invasive aspergillosis . milestone descriptions and reports of diseases caused by aspergillus species aspergillus is pathogenic in birds , animals , and human beings . the route of infection is through either the gastrointestinal tract or the respiratory tract , and infections may occur anywhere along these routes . invasive forms are the most severe and aggressive types , and cause gross morbid soft tissue and bone destruction and death . veress et al . reported that two factors may play an important role in paranasal sinus aspergillosis as follows : 
 secretion of a toxic substance by fungi that penetrates into tissues under appropriate conditions andinduction of tissue necrosis caused by an immune mechanism . secretion of a toxic substance by fungi that penetrates into tissues under appropriate conditions and induction of tissue necrosis caused by an immune mechanism . however , invasive aspergillosis is usually seen in healthy or mildly immunocompromised host , as seen in our case who was an old patient with history of hypertension , which could be considered as mid immunocompromised state . stevens emphasized that functional obstruction of the sinus osteum may result in aspergillus infection and that the fungus favors hypoxic or anaerobic conditions . aspergillosis developing in tissues of resistance or in an antrum such as the nasal sinuses will ideally be ball - shaped ( fungus ball ) or necrotic material that is green - black and of a cheesy consistency or oral aspergillosis lesions , which are yellow or black in color . noninvasiveinvasivedestructive noninvasive types , which is further classified into : 
 aspergillomafungus ballmycetoma ( usually affecting one sinus ) or aspergillus sinusitis ( involving more than one sinus ) . destructive noninvasive types , which is further classified into : 
 aspergillomafungus ballmycetoma ( usually affecting one sinus ) or aspergillus sinusitis ( involving more than one sinus ) . mycetoma ( usually affecting one sinus ) or aspergillus sinusitis ( involving more than one sinus ) . invasive type represents true fungal tissue invasion that can be either slowly progressive or destructive ( nonfulminant ) or highly aggressive and lethal fulminant . invasive aspergillus sinusitis is characterized by rapid spread of fungus from the sinus airspace into the adjacent structures . rarely , invasive aspergillosis has been reported to affect the paranasal sinuses of apparently normal immunocompetent individuals , which was seen in our case . thus , most patients with chronic invasive aspergillosis have no discernible immunocompromising factors , although substantial majorities are diabetics , drink alcohol to excess , or have acquired immune deficiency syndrome ( aids ) . as the disease progresses , usually over months , the clinical features of local involvement become apparent . visual symptoms are common and include diplopia , headaches , loss of impairment of smell , and features of chronic sinusitis ( e.g. nasal stuffness ) . fever is almost universally absent ; all these hallmarks of chronic invasive aspergillosis were present in our case . bone destruction may occur without direct fungal invasion , apparently due either to a  pressure  effect or to a local toxin production ( speculative ) . histopathologically , invasive lesions comprise chronic granulomatous reactions and appear like any of the granulomas of sarcoidoses , midline lethal granuloma , or foreign body granuloma . though hyphal forms can be seen , in the center of an area of necrosis , they are faintly seen in hematoxylin and eosin stained sections , they may go unnoticed unless selective special stains like methanamine silver are employed . they appear as septate hyphae , with branching at 45 angles and are about 24 mm in diameter . this fungus differentiated from mucormycosis were broader non - septate hyphae with dichomatous brancing at 90 angles is observed . . however , bone invasion by hyphae may be under - recognized histopathologically because of the nature of the surgery . no skin sensitivity or serum reactivity tests are useful , because most of the affected patients are immunodeficient . case fatality rate of 66% was recorded for sinus aspergillosis studied in a systemic review by lin et al . the diagnosis of aspergillosis in humans relies heavily on the clinical circumstances of the infection , the anatomic site , and the microscopic findings . early recognition of these diseases and especially differentiating it from malignant lesions and other granulomas of the sinuses are very important as its presentation is very deceptive and misleading . however , from a practical standpoint treatment may need to be initiated immediately to prevent the patient demise .
aspergillosis of the nasal and paranasal sinuses is recognized as being second to candidiasis , among opportunistic fungal infections in immunocompromised patients . however , invasive variant in normal and mildly immunocompromised hosts is a very rare occurrence . 
 we report one such case of aspergillosis involving paranasal sinuses in mildly immunocompromised patient .