A brief presentation of mucormycosis cases as experienced at North Bengal Medical College, Darjeeling

1. MUCORMYCOSIS IN
OTORHINOLARYNGOLOGY
DEPARTMENT OF
OTORHINOLARYNGOLOGY AND HEAD
NECK SURGERY
NORTH BENGAL MEDICAL COLLEGE &
HOSPITAL

2. Invasive fungal
rhino-sinusitis
Acute invasive
fungal sinusitis
Chronic invasive
fungal sinusitis
Non-invasive fungal
rhino-sinusitis
Fungal balls
Saprophytic fungal
infections
Allergic fungal
rhino-sinusitis
FUNGAL RHINO-SINUSITIS

3. ACUTE INVASIVE FUNGAL RHINOSINUSITIS
Presence of hyphal invasion
of sinus tissues in a time
course less than 4 weeks
HPE:
• Mycotic invasion of blood vessels
• Vasculitis with thrombosis
• Tissue infarction
• Haemorrhage
• Acute necrotic infiltrates
Seen in SEVERELY IMMUNO-COMPROMISED
patients:
• Uncontrolled T2DM
• AIDS
• Iatrogenic immunosuppression
• Organ transplantation
• Haematological malignancies

4. Mucormycosis is an invasive fungal infection
first described by Paulltauf A in 1885

5. The causative agents of mucormycosis are the filamentous fungi of the
Mucoraceae family of the order Mucorales, subphylum Mucormycotina
MUCORMYCOSIS: broad, ribbon-like (10-15 mm),
irregular, rarely septate

6. MANIFESTATIONS OF MUCORMYCOSIS
• Rhino-orbito-cerebral
• Pulmonary
• Gastro-intestinal
• Disseminated

7. RHINO-ORBITO-CEREBRAL
MUCORMYCOSIS

8. CLINICAL PRESENTATIONS
• Earliest symptoms: nasal dryness, crusting, brownish or bloody
discharge
• Paraesthesia/anaesthesia of cheek, gum, teeth, local pain
• Late features: facial swelling, peri-orbital swelling, severe
headache, nasal blockage with pus, loose maxillary teeth
• Progressive painless loss of vision
• Black eschar

9. BLACK ESCHAR

10. INVESTIGATIONS
• Radiological investigations: CT Scan and Contrast Enhanced MRI
• Diagnostic nasal endoscopy
• Staining and culture of endoscopic samples
• Tissue biopsy

11. RADIOLOGICAL INVESTIGATIONS
CT SCAN FINDINGS:
• Varying degrees of sinus
opacification
• Rim of soft tissue thickness
along paranasal sinuses
• Bone erosion

12. MRI FINDINGS
• T1: Isointense lesions
relative to brain in
most cases
• T2: Fungal elements
have low signal
• CONTRAST:
Devitalized mucosa
appears as contiguous
foci of non-enhancing
tissue (black turbinate
sign)

13. DIAGNOSTIC NASAL ENDOSCOPY
COMMON SITES:
• Middle turbinate
• Middle meatus
• Nasal septum
• Inferior turbinate
• Ethmoid sinus
VIDEO

14. • Active
• Recovering
• Post-discharge
More common in:
• Uncontrolled T2DM
• Steroid receipients

15. High risk factors:
• Lymphopenia
• Injudicious use of steroids
• High levels of IL6 and ferritin
• Neutropenia
• Uncontrolled T2DM
• Prolonged use of broad-spectrum antibiotics
• Tocilizumab?
• Zinc?

16. MANAGEMENT OF RHINO-ORBITO-CEREBRAL
MUCORMYCOSIS
Control of immuno-
compromised state
Surgical
management
Anti-fungal therapy

17. • Good glycaemic control in diabetics
• Systemic steroids only to be used for patients with
hypoxaemia
• Blood sugar monitoring for steroid recipients
• Dexamethasone: 0.1mg/kg/day for 5-10 days
• Limiting injudicious use of other immune-modulators
CONTROL OF IMMUNO-COMPROMISED
STATE

18. SURGICAL MANAGEMENT
INDICATIONS:
• Mainstay for disease
control
• Microbiological
diagnostics
• HPE
DEBRIDEMENT OF ALL
NECROTIC TISSUES WITH
CLEAR MARGINS UNTIL
HEALTHY TISSUE IS
ENCOUNTERED (bleeding
from bones/healthy mucosa)

19. APPROACHES FOR SURGICAL DEBRIDEMENT
External
approach Endoscopic
approach

20. ENDOSCOPIC APPROACHES FOR
DEBRIDEMENT
INSTRUMENTS:
• Endoscopes: 0, 30, 45, 70 degrees
• Micro-debrider set
• Power suction
• Blakesley forceps: straight/angulated
• Lucs forceps
• Light source
• HD camera

21. ENDOSCOPIC APPROACHES FOR
DEBRIDEMENT
• Endoscopic middle meatal antrostomy with debridement
• Endoscopic inferior and/or middle turbinectomy
• Endoscopic modified Denker’s approach to para-nasal sinuses
• Endoscopic ethmoidectomy
• Endoscopic sphenoidotomy +/- posterior septectomy: lateral/medial/intermediate
approaches
• Endoscopic trans-orbital approach for debridement of medial orbital contents
• Endoscopic approach to frontal sinus
• Endoscopic approaches to the anterior skull base
ALL THESE APPROACHES CAN BE DONE AS PART OF
FULL HOUSE FUNCTIONAL ENDOSCOPIC SINUS
SURGERY (FESS)
VIDEO

22. EXTERNAL APPROACHES FOR
DEBRIDEMENT
INDICATION:
EXTENSIVE INVOLVEMENT OF
PARANASAL SINUSES, SKIN, HARD
PALATE, ORAL MUCOSA, ORBIT AND
INTRA-CRANIAL EXTENSION

23. EXTERNAL APPROACHES FOR
DEBRIDEMENT
• MEDIAL MAXILLECTOMY
• TOTAL MAXILLECTOMY WITH/WITHOUT THE FOLLOWING
1. ORBITAL EXENTERATION
2. DRILLING OF PTERYGOID PLATES
3. DEBRIDEMENT OF PTERYGO-PALATINE FOSSA
• ANTERIOR CRANIO-FACIAL RESECTION
• NEUROSURGICAL INTERVENTION

24. POST-RESECTION
RECONSTRUCTION OPTIONS IN
FACE:
• SPLIT THICKNESS SKIN GRAFTING
• FULL THICKNESS SKIN GRAFTING
• TEMPORO-PARIETO-FACIAL FLAP
• TEMPORALIS MUSCLE FLAP
• PER-CRANIAL FLAP
• FOREHEAD FLAPS
• CERVICO-FACIAL ADVANCEMENT
• FREE RADIAL FORE-ARM FLAP
• FREE RECTUS ABDOMINIS FLAP
Can be used for
reconstruction of
defects after Total
maxillectomy with
orbital exenteration

25. ANTI-FUNGAL THERAPY
• LIPOSOMAL AMPHOTERICIN B: 5mg/kg/day + 200cc 5%D over 2-3
hours; 10mg/kg/day in case of brain involvement
• AMPHOTERICIN B: 1.0-1.5mg/kg/day + 200cc 5%D over 2-3 hours
• TAB POSACONAZOLE: 300mg BD on D1, 300mg OD
• TAB ISAVUCONAZOLE: 200mg TDS for 2 days, 200mg OD
• 3-6 weeks of Amphotericin B therapy f/b consolidation therapy of 3-6
months
Fungal infection study forum

26. PROTOCOL FOR AMPHOTERICIN B/LIPOSOMAL
AMPHOTERICIN B ADMINISTRATION
PRE-HYDRATION:
• 500ml Normal Saline infusion 2 hours prior
• To reduce hypokalaemia and reduce nephrotoxicity: 500ml NS + 1 amp (20cc) KCL
HYDRATION:
• Dilution: 1mg in 10ml
• Always in 5%D or 10%D
• Avoid Normal Saline
• Protect from light during administration

27. LANCET guidelines for POSACONAZOLE
PROPHYLAXIS in HIGH RISK Category like
1. Uncontrolled T2DM
2. Immunocompromised
3. Neutropenics
4. High IL6
5. High Ferritin
6. High CT score needing Mechanical
ventilation/High dose steroids/Tocilizumab

28. TAKE HOME MESSAGE
• COVID-19 associated Mucormycosis is a life threatening
disease
• Visual impairment is very common
• Injudicious steroid therapy and poor Glycaemic control
is the prime aggravating factor
• Every case of Severe Covid-19 disease should undergo
routine Diagnostic Nasal Endoscopy and Imaging
studies for early diagnosis and Follow-up
• Early aggressive therapy is the key for survival