aspergillosis is the most common fungal infection of the paranasal sinuses and it usually occurs unilaterally in maxillary sinus . on the other hand ,
transverse maxillary deficiency ( tmd ) is one of the most common skeletal dysplasias observed in clinical practice .
it can be treated with several techniques such as slow orthodontic expansion , rapid palatal expansion , and surgically assisted rapid palatal expansion ( sarpe ) , and the recommended technique for adult patients is sarpe because of limited osteogenic activity of palatal suture .
the use of sarpe to treat tmd decreases adverse effects of orthodontic expansion such as lateral tipping of posterior teeth , extrusion , periodontal membrane compression , buccal root resorption , alveolar bone bending , fenestration of the buccal cortex , palatal tissue necrosis , inability to open the midpalatal suture , pain , and instability of the expansion .
although sarpe is a relatively easy and an effective operation , complication possibility due to technical sensitivity of surgical approach and patient 's systemic condition must be considered . in this case report
, perforation - related fistula formation on inferior meatus and unilateral aspergillosis infection in maxillary sinus associated with sarpe , treated with functional endoscopic sinus surgery ( fess ) , were evaluated .
a 32-year - old systemically healthy woman with tmd was referred from the orthodontics department .
the patient was operated under general anesthesia with nasal endotracheal intubation . before the surgical procedure ,
expansion device was activated . following the full - thickness sulcular incision on the deepest level of the vestibular sulcus incision , the lateral surface of the maxilla was exposed with subperiosteal dissection .
nasal mucosa was elevated from the lateral nasal wall without any perforation , and bilateral corticotomy starting from the pyriform aperture to the pterygomaxillary fissure was performed .
the medial walls of maxillary sinuses were separated bilaterally using guided osteotomes , and the palatal suture was separated using sharp chisel osteotome .
the incision was closed primarily , and anterior nasal packs ( merocel standard dressing ) were applied .
the patient was discharged on the same day , and the 1 week of healing period was uneventful .
the patient consulted an ent specialist and computed tomography revealed that the left middle meatus was congested with radiopaque substance [ figure 1 ] .
besides , endoscopic sinus examination showed that there was pus drainage from maxillary sinus to inferior meatus through fistula [ figure 2 ] , and augmented amoxicillin with clavulanic acid ( augmentin , 1 g ) was prescribed for 2 weeks to control sinusitis . computed tomography imaging of congested ostium and radiopaque appearance defluxion from fistula after 2 weeks
, a granulation tissue in the maxillary sinus was observed during the endoscopic examination [ figure 3 ] , and fess was performed for decontamination of the maxillary sinus and correction of ostium function .
augmented amoxicillin with clavulanic acid ( augmentin , 1 g ) was prescribed for 2 weeks again after fess , and histopathological examination of the substance removed from the sinus revealed aspergillosis [ figure 4a  c ] .
granulation formation ( a ) middle meatal antrostomy , ( b ) removal of substance located in the maxillary sinus , ( c ) postoperative appearance of the middle meatus after 3 weeks , it was observed that the ostium was functioning and there was no sign of aspergillosis . in 3 months
correction of tmd in adult patients is more challenging because of changes in osseous articulations of the maxilla with adjoining bones .
procedures described for the correction of tmd have conventionally been grouped into two categories as segmenting the maxilla during the le fort 1 osteotomy in a widened transverse dimension and sarpe .
however , sarpe has become a common procedure and it has been considered as the procedure which has the lowest morbidity incidence , especially when compared with other orthognathic surgery procedures .
sarpe allows clinicians to achieve satisfactory maxillary expansion in a skeletally mature patient and it decreases adverse effects of orthodontic expansion . although sarpe is a relatively simple procedure among other orthognathic surgery techniques , complications related with surgical technique and systemic condition of the patient must be considered . in this case ,
fistula formation between the maxillary sinus and the inferior meatus occurred during osteotomy step of sarpe procedure , and the alteration of the sinus ventilation was complicated by the presence of aspergillosis .
it is well - known data that the use of wide broad spectrum antibiotics in a long period can cause fungal infection .
the middle meatus dysfunction and the operation trauma are other reasons of aspergillosis formation in this case .
although potential association between aspergillosis and sarpe was not described before in literature , it must be noted that sarpe causes perforation and fistula formation between the nasal cavity and maxillary sinuses .
despite the frequent use of the procedure , only limited data on the prevalence of postoperative complications after sarpe are available in literature . on the other hand , some severe and unusual complications have been reported .
it should be noted that fistula formation and meatus dysfunction related with sarpe operation cause fungal infection development .
 surgically assisted rapid palatal expansion ( sarpe ) is one of the most common orthognathic surgery operations for the treatment of maxillary transverse deficiencies . 
 although this operation is considered technically simple and has low complication rate , predisposing factors can complicate the postoperative period . in this case report , 
 fistula formation and aspergillosis after sarpe operation were presented . 