osteomyelitis is defined as inflammation of the medullary cavities , haversian system and adjacent cortex of bone . in the present era of antibiotics , osteomyelitis of facial bones osteomyelitis involving maxilla is quite rare compared to that of mandible because of the extensive vascularity and strut like nature seen in maxilla . the diagnostic workup with emphasis on special staining in histopathological sections to identify the fungal nature has been discussed . patients who reported for osteomyelitis were thoroughly screened and only five cases were obtained which showed characteristics of fungal osteomyelitis . all five cases included in the series were primarily intraosseous with evidence of radiographic changes in bone . all cases had relevant clinical [ figure 1 ] , radiological [ figure 2 ] and histopathological [ figures 3 , 4 and 5 ] data . biopsied tissue sections were stained with h&e , periodic acid schiff ( pas ) and grocott methenamine silver ( gms ) stain . in all cases , 14 , 15 and 16 ; ( b ) case 5-clinical photograph showing oro - antral fistula in right maxillary vestibule , measuring 43 cm ( a ) case 1-radiographs showing radiopaque interdental septum i.r.t . ( b ) case 3- ct scan showing permeative bone destruction in anterior hard palate . 14,15 and 16 with haziness in right maxillary sinus in case 5 ( a ) case 2- section showing candidal pseudoseptate hyphae [ periodic acid schiff ( pas ) stain , 400 ] . ( b ) case 4- section showing empty lacunae in bone and candidal pseudoseptate hyphae [ pas stain , 40 ] . inset : higher magnification showing candidal pseudohypae [ pas , 400 ] case 4- section showing actinomycotic foci within bone ( h&e stain , 200 ) , ( b ) grocott methenamine silver ( 200 ) and h&e ( inset , 400 ) stained section showing septate and dichotomous hyphae of aspergillosis , ( c ) grocott methenamine silver stain showing aseptate broad , ribbon shaped hyphae of mucormycosis ( 400 ) ( a ) case 1- section showing necrotic bone with aseptate hyphae ( h&e stain , 200 ) , ( b ) case 3- sections showing broad aseptate hyphae and spores ( h&e stain , 400 ) the clinical , radiological , histopathological and treatment data are illustrated in table 1 . osteomyelitis is an inflammatory condition of bone and bone marrow content which originates from chronic infection . etiopathogenesis includes trauma , surgical intervention , bacteremia , fungal infection or a contiguous infectious focus and systemic diseases among the innumerable causes . it is further influenced by the immobility of stagnant blood which acts as nidus for the development of infection . these are opportunistic infections which frequently enter the body due to a decrease in host defense or through an invasive gateway , such as a dental extraction . candidal infection is more often encountered when compared to other fungal infection , i.e. mucormycosis , aspergillosis etc . however , fungi , parasites and viruses can also affect bone and bone marrow . since fungal infections involving bone occur infrequently , it can pose a diagnostic and therapeutic dilemma for those who are not familiar with its clinical presentation , hence leading to ineffective treatment or resolution . specific delineating features would be the involvement of maxillary sinus with a complaint of sinusitis in maxillary fungal osteomyelitis . . diabetes mellitus is usually a propagating factor for maxillary osteomyelitis . out of five cases , three were involving the maxilla with a history of diabetes in two out of three cases . altered immunity and compromised vascularity are well established and are commonly encountered facts related to uncontrolled diabetes mellitus ( udm ) . the mechanism which facilitates bone infection includes diminished leukocyte chemotaxis , phagocytosis and life span ; and diminished vascularity , thus reducing tissue perfusion . an incidence of 45.1% of maxillary osteomyelitis has been reported by koorbusch et al . among udm patients in a rural indian population . collateral blood supply , porous nature and thin cortices of maxilla , reduces the chance of osteomyelitis in maxilla when compared to the mandible . however , the current series showed a slight predominance of fungal osteomyelitis in maxilla over mandible . according to niranjan et al . , 52% cases of fungal osteomyelitis and 48% of nonfungal osteomyelitis were observed in a 10 year study conducted on north karnataka population . maxillary involvement was seen in 80.76% of cases with male predominance associated with diabetes mellitus . a thorough review of literature showed that the incidence ratio of maxilla : mandible osteomyelitis was 1.07:1 by peravali et al . , whereas the incidence of 1:6.5 and 1:6 was noted by koorbusch et al . and the biopsied bony tissues on decalcified sections show irregular bony trabeculae with empty osteolytic lacunae . culture sensitivity should be followed in all cases irrespective of its nature . in the current study , identification can be accurately done on histopathological sections itself and the culture will confirm the exact species . the fungus invades the arteries leading to thrombosis that subsequently causes necrosis of hard and soft tissues . mucormycosis is frequent in diabetic patients because a favorable environment is created due to an excess of ketone bodies in diabetic patients . rhizopus arrhizus , produces the enzyme ketoreductase , which allows them to utilize the patient 's ketone bodies . literature reveals that zygomycosis is less documented in mandible with only five cases of mandibular zygomycosis being reported until date . pas stained histopathological sections showed pseudoseptate hyphae in clusters with budding at focal areas ( case # 2 and case # 4 ) . have analyzed 31 cases of osteomyelitis in which there appears to be only one case of candidal osteomyelitis , along with three cases of mucormycosis and one case of aspergillosis . it is extremely rare to find candidal osteomyelitis in the maxilla and because of nonspecific symptoms , diagnosis is very challenging . it is usually invasive in nature when involving maxillary sinus though noninvasive forms have also been reported and does not cause bone destruction when compared to mucormycosis . a thorough search in pubmed reveals only one case of trifungal osteomyelitis reported till date . the identification of these hyphae are quite characteristic with aspergillosis showing narrow septate hyphae of 36 m in size having dichotomous branching between 45 and 90. mucormycosis which belongs to zygomycetes family typically shows broad aseptate hyphae of size 620 m with branching at > 90. histopathological identification can be considered as the gold standard in such cases . appropriate treatment of antifungal regime needs to be initiated as the culture sensitivity results could take up to 6 weeks . early identification and prompt treatment with the identification of underlying systemic disease would lead to successful outcome . in the present study , two cases of candidal osteomyelitis ( case#2 and case # 4 ) healed with appropriate antifungal regime of itraconazole and fluconazole along with surgical debridement . case#3 was administered with amphotericin b , cefotaxime and metronidazole which was followed by the complete removal of maxillary sinus lining with excision and closure of oroantral fistula by the nasolabial flap . case#5 underwent sequestrectomy with reconstruction with buccal fat pad and irrigation , followed by drugs , i.e. amoxicillin , clavulanic acid and itraconazole . all cases were followed up for renal toxicity for 6 months with an interval of 1 month . osteomyelitis of facial bones needs to be investigated thoroughly as there is no difference in clinical presentation between bacterial and fungal osteomyelitis unless accompanied by maxillary sinusitis . the diagnostic workup with biopsy and culture sensitivity helps to identify the pathogen at the earliest . fungal osteomyelitis is very rare and appropriate treatment with antifungal regime and timely surgical intervention , i.e. , debridement , curettage , sequestrectomy will lead to successful resolution of the disease process .
osteomyelitis is defined as inflammation of the medullary cavities , haversian system and adjacent cortex of bone . 
 osteomyelitis involving maxilla is quite rare when compared to that of mandible . 
 fungal osteomyelitis is very rarely seen and documented in the maxillofacial area . 
 it is devastating to patients if it is invasive in nature . 
 a prospective study was undertaken from december 2011 to december 2013 . 
 biopsied hard tissue bits were decalcified and sections were stained with h&e , periodic acid schiff and grocott methenamine silver . 
 culture sensitivity was carried out in all cases . surgical intervention followed by antifungal therapy 
 was advocated to treat the patients . 
 the current series showed five cases of fungal osteomyelitis which included candidal osteomyelitis , aspergillosis and mucormycosis with slight predominance of maxilla over mandible . 
 osteomyelitis of facial bones needs to be investigated thoroughly as there is no difference in clinical presentation between bacterial and fungal osteomyelitis . 
 the diagnostic workup with biopsy and culture sensitivity helps to identify the pathogen at the earliest . 
 appropriate antifungal treatment needs to be advocated for successful treatment .