Is mucormycosis the end? A comprehensive management of orbit in COVID associated rhino-orbital–cerebral mucormycosis: preserving the salvageable

Abstract

Background Rhino-orbital–cerebral mucor mycosis (ROCM) is a relatively rare opportunistic infection caused by the Mucorales species. While ROCM suggests involvement of the paranasal sinuses, orbit and brain ROM (rhino-orbital-Mucormycosis) stands for the fungal invasion in sinuses and orbit sans cerebral involvement. In India with the outbreak of the second COVID wave and the delta variant of the virus, there has been a steep increase in this opportunistic fulminant fungal infection, named COVID-associated Mucor mycosis (CAM). The most critical question in orbital management is when to go ahead with an exenteration. Our study aims to design a pertinent minimal invasive surgical protocol for surgeons to manage such cases based on our surgical experience and mitigate the need for exenteration and save the eyes wherever possible. Methods The study is a retrospective analysis of patients of ROM with and without brain involvement, who underwent minimal surgical management between March 2021 to March 2022 along with their follow-up. Results There were 184 eyes of 148 patients diagnosed with CAM. The mean age was 51.7 years with a male predominance of 103 (70%). All patients developed ROM following the COVID-19 infection and the duration between diagnosis of COVID-19 and ROM was 36 ± 23 days. 18 cases (12%) were bilateral. 76 eyes (41%) had no vision at the presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (61%), cavernous sinus involvement (53%), and central nervous system (CNS) involvement (47%). All the patients (100%) were treated with systemic Liposomal amphotericin-B and sinus debridement. Endoscopic debridement of the orbital disease was performed in 45 (30.4%) cases, 15(8.1%) eyes underwent exenteration and were later rehabilitated with a customized ocular prosthesis, 103 (56%) eyes underwent transcutaneous retrobulbar amphotericin-B. At a mean follow-up of 13.1 months; the complete resolution was seen in 25 (17%) cases, the residual stable lesion was seen in 77(52%) of the cases and new lesions were developed in 13(9%) of the cases. Mortality was seen in 33 (22%) patients and all of them had CNS involvement. Conclusions Systemic and protocol-based management can save the life and salvage the eyes.

Outcome Of Total Surgical Debridement Of Covid Associated Skull base Mucormycosis Based on a New Surgical Staging System: Evidence From A Cohort Study

“…In our study residual disease was seen in 4.6% of cases which is comparatively much less compared to other contemporary studies. (15) Out of the total cohort, 94.8% patients had no evidence of disease during follow-up, ranging from 6 to 18 months.…”

“…Therefore, a higher stage does not necessarily mean involvement of structures in the lower stages. (15) Our study proposes a detailed protocol for the surgical management of invasive skull base fungal osteomyelitis, based on the radiological assessment of disease and its progression.…”

“…EMDA also facilitates trans-pterygoid approaches and aids in post-operative inspection of operated areas to pick up early disease changes. Surgical treatment of mucormycosis has been defined over time as 'debridement until fresh bleeding' (15) . But we stress on 'defining the debridement with anatomical boundaries' for better surgical outcome.…”

“…The surgical treatment for mucormycosis over time is ‘debridement till healthy bleeding. (15) However, we stress on ‘defining the debridement with anatomical boundaries’ for better surgical outcome. Unlike malignancies, the disease pattern in ROCM may not always be contiguous.…”

“…In our study residual disease was seen in 4.6% of cases which is comparatively much less compared to other contemporary studies. (15)…”