Objectives: Maxillary sinus fungal balls (MSFBs) mostly occur in older individuals and demonstrate female predominance. Early diagnosis is important to avoid treatment delays. This study aimed to elucidate the differences in clinical and imaging presentation of MSFB with and without intralesional hyperdensity (IH). Design and setting: This was a retrospective review in a tertiary medical center. We retrospectively identified 588 patients underwent endoscopic sinus surgery procedures for MSFB between 2005 and 2018. The clinical characteristics and computed tomography (CT) findings including the presence of complete or partial opacification, IH, and odontogenic pathology were reviewed. Participants: 588 MSFB patients Results: Patients with unilateral MSFB had a mean age of 57.4 years and demonstrated female predominance (64.63%). The overall female-to-male ratio was highest at 51-60 years (2.02) and rose to 2.60 in MSFB with IH only. Compared to those with IH, MSFB without IH was significantly more common in males (OR = 2.496; P < .0001), in those with diabetes mellitus (DM) (OR = 2.094; P = .010) and adjacent maxillary odontogenic pathology (OR = 1.697; P = .030). Complete opacification on CT was less common in MSFB without IH (OR = 0.617; P = .025). Conclusion: The highest female-to-male ratio for MSFB at 51-60 years corresponded to the age of menopause. Patients with MSFB without IH were more likely to have DM, no female predominance, adjacent maxillary odontogenic pathology, and partial opacification of the sinus, compared to those with IH. These clinical features may aid earlier identification of MSFB without IH.