Our experience in endoscopic management of mucormycosis: a case series and review of literature

Abstract

Sinonasal mucormycosis is uncommon entity and it rarely infects a healthy host. When it does occur; it becomes very difficult to treat because of the speed of progress of disease and can have fatal outcomes. The mainstays of therapy are treatment of immunocompromised status, systemic high dose Amphotericin B, and surgical debridement of necrosed or nonviable tissue. The following six cases, managed at our centre from July 2016 to October 2016, outline nuances in the diagnosis of invasive sinonasal mucormycosis and highlight the importance of timely surgical debridement and importance of endoscopic approach in complete clearance of disease in order to facilitate medical management to work. All cases included in this study were found to be immunocompromised and had unilateral severe diminution of vision due to periorbital extension of disease. Diagnostic nasal endoscopy revealed black-brown crust and tenacious pus filling up nasal cavity, erosion of turbinates and nasal septal perforation. One patient showed erosion of hard palate and eschar formation. CECT/MRI of PNS showed evidence of bony erosion and orbital involvement. Biopsy taken during nasal endoscopy confirmed the presence of mucormycosis. All patients were started on Liposomal Amphotericin B and broad spectrum antibiotics in renal corrected dosages and taken up for urgent endonasal endoscopic debridement. All paranasal sinuses were cleared and orbital decompression was done. Postoperatively all patients were continued on Liposomal Amphotericin B in renal corrected dosages for two-three weeks and being followed up monthly. One patient could not survive due to several co morbidities and severe immunocompromised status. Only one patient showed recurrence of disease on one month postoperative follow up. Five patients showed improvement in visual acuity. Sinonasal mucormycosis if inappropriately diagnosed and treated can be a fatal condition. Energetic diagnostic workup, combined with equally energetic management, surgical and management leads to favourable outcome.<p> </p>

A rare case of rhino-orbito-maxillary mucormycosis having no common signs and laboratory findings but no visible morbidity

“…Out of which, rhinocerebral mucormycosis is the most common type though very little is known about it since it was not a reportable disease before [8]. Rhinomaxillary mucormycosis, a variant of rhinocerebral mucormycosis, is the most common, whose symptoms include proptosis, loss of vision, nasal discharge, sinusitis, palatal necrosis, and perforation [7,9]. In this case, however, all these symptoms were evasive.…”

“…generally develops secondary to immunosuppression or debilitating disease [7]. Throughout the history of mucormycosis, from the first case in humans reported by Platauf, in 1885, through the publication of the first observation of rhino-orbito-cerebral mucormycosis in 1943 by Gregory et al, to the report of the first known survivor in 1955 by Harris, little has changed in the diagnosis and outcome of this disease [3,8].…”

Study of Clinicoepidemiology and Surgical Complications in Acute Invasive Fungal Rhinosinusitis

“…Coronavirus disease causes immunosuppressed state in patients which increases the risk of secondary fungal infection like mucormycosis [ 2 ]. COVID-19 associated with onset of diabetes and diabetic ketoacidosis (DKA) due to prolong use of systemic or oral steroids and antibiotics in treatment of COVID-19.…”

Total eyelid complex sparing orbital exenteration for mucormycosis

“…2,13 Recently, total eyelid preserving orbital apex clearance has been described using an endoscope. 14,15 The rationale behind 'total' lid sparing exenteration is to reduce the morbidity, as it has the potential to hasten wound healing and improve functional and cosmetic rehabilitation. 4 Mucormycosis is a non-malignant disease and sparing the lids is justified under the cover of amphotericin B if gross involvement is not present.…”