(1) The patient presented with pain, swelling and nasal discharge in the left side of the face for one month. They had a history of diabetes and hypertension. (2) Clinical examination and investigations revealed elevated blood sugar and low hemoglobin. A provisional diagnosis of squamous cell carcinoma or chronic infection was made. (3) The final diagnosis was rhino-orbital mucormycosis based on fungal hyphae in biopsy. Treatment involves antifungal therapy, surgical debridement and control of underlying conditions.

1. OBJECTIVE STRUCTURED
CLINICAL EXAMINATION
DEPARTMENT OF ORAL AND
MAXILLOFACIAL SURGERY
JKKN DENTAL COLLEGE
BY DR.S.VINODTHANGASWAMY
21-06-2022

2. • CHIEF COMPLAINT:-Patient complaints of pain & swelling
in the left side of the face & discharge from the left nostril for
the past one month.
• HOPI:-Patient initially had pain which was followed by the
• swelling & nasal discharge
• PAST MEDICAL HISTORY:-Pt is a known diabetic &
hypertensive on medication.
• SURGICAL HISTORY:-Pt has undergone surgical procedure
in the right side of the facial region before seven years.

3. • GENERAL EXAMINATION:-
• SYSTEMIC EVALUATION:-
• CLINICAL EXAMINATION:-
• EXTRALORAL
• INTRAORAL

4. • ROUTINE HEMATOLOGICAL INVESTIGATIONS
• RADIOLOGICAL INVESTIGATIONS
• PROVISIONAL DIAGNOSIS
• D.D:-

5. PREOPERATIVE

6. PREOPERATIVE

7. On biochemical investigation’s:-
elevated fasting blood sugar level
decreased hemoglobin% (7 g %)
HbA1c level was 10.2

8. Clinical differential diagnosis of lesion:-
1)squamous cell carcinoma,
2)chronic granulomatous infection such as
tuberculosis,
3)tertiary syphilis,
4) midline lethal granuloma,
5)other deep fungal infections
a)Aspergillosis
b)Acremonium

9. FINAL DIAGNOSIS

10. The successful treatment of
mucormycosis requires 4 steps:-
(1) early diagnosis
(2) reversal of underlying
predisposing risk factors, if possible
(3) surgical debridement where
applicable
(4) prompt antifungal therapy

11. INTRA-OPERATIVE

12. POSTOPERATIVE

13. POSTOPERATIVE

14. POSTOPERATIVE

18. Amphotericin B
In classic desoxycholate form in the dose of 1–1.5
mg/kg/day or
more preferably in the liposomal form of
amphotericin B is
highly useful for mucormycosis
TOTAL DURATION OF ANTIFUNGAL DRUG TREATMENT IN MUCORMYCOSIS
VARIES WITH EVOLUTION BUT AT LEAST ADVISED FOR 12 WEEKS.
Amphotericin B
has potential toxicity on renal function, and so dose
should be individually adjusted between 0.5 mg/kg/day
and
1.0 mg/kg/day on the basis of body weight and renal
functions
of the patients. The total cumulative dosage of
amphotericin
B is 2–4 g often advocated to the adult patien

19. Patients were treated with isavuconazole IV or orally.
Median treatment duration was
102 days for patients with primary mucormycosis,
33 days for those with refractory mucormycosis,
85 days for those with intolerance to other antifungal
therapy.
Isavuconazole azole antifungal, has
also been reported to be efficacious
in the treatment of rhinocerebral
mucormycosis that is refractory to
amphotericin B and Posaconazole.

20. Hyperbaric oxygen therapy
Hyperbaric oxygen therapy has a fungistatic effect
and helps revascularization of the necrotic or
ischemic tissue
Certain cytokines such as granulocyte macrophage-
CSF and interferon gamma act as adjuvant
treatment(these are under assessment).

21. DISCUSSION

22. Types of fungi that cause mucormycosis
Several different types of fungi can cause
mucormycosis. These fungi are called mucormycetes
and belong to the scientific order Mucorales.
The most common types that cause mucormycosis
are Rhizopus species and Mucor species.
5 Other’s:-
include Rhizomucor species, Syncephalastrum specie
s, Cunninghamella bertholletiae, Apophysomyces,
Lichtheimia (formerly Absidia),
Saksenaea, and Rhizomucor.

23. Pathophysiology :-
Inhalation of spores through the nose or mouth or even
through a skin laceration. (Individuals with compromised
cellular and humoral defense mechanisms may generate
inadequate response).

25. Diabetes mellitus tends to change the normal immunological response of
body to any infection in several ways. Hyperglycemia stimulates fungal
proliferation and also causes decrease in chemotaxis and phagocytic
efficiency which permits the otherwise innocuous organisms to thrive in
acid-rich environment. In the diabetic ketoacidosis patient, there is an
increased risk of mucormycosis caused by Rhizopus oryzae as these
organisms produce the enzyme ketoreductase, which allows them to utilize
the patient's ketone bodies.[8] It has been established that diabetic
ketoacidosis temporarily disrupts the ability of transferrin to bind iron,
and this alteration eliminates a significant host defense mechanism and
permits the growth of Rhizopus oryzae

26. Predisposing factors for mucormycosis are:-
1)uncontrolled diabetes (particularly in patients
having ketoacidosis),2)malignancies such as
lymphomas and leukemias,3) renal failure,4)organ
transplant,5)long-term corticosteroid and
immunosuppressive therapy,6)cirrhosis,7)burns,
8)protein-energy malnutrition, and 9)acquired
immune deficiency syndrome (AIDS).

27. Types of Mucormycosis:-
•Rhinocerebral (sinus and brain) mucormycosis is an infection in the
sinuses that can spread to the brain. This is most common in people with
uncontrolled diabetes and in people who have had a kidney transplant.
•Pulmonary (lung) mucormycosis is the most common type of
mucormycosis in people with cancer and in people who have had an organ
transplant or a stem cell transplant.
•Gastrointestinal mucormycosis is more common among young children
than adults. Premature and low-birth-weight infants less than 1 month of
age are at risk if they have had antibiotics, surgery, or medications that
lower the body’s ability to fight germs and sickness.6-7
•Cutaneous (skin) mucormycosis occurs after the fungi enter the body
through a break in the skin. This type of infection might occur after a
burn, scrape, cut, surgery, or other types of skin trauma. This is the most
common form of mucormycosis among people who do not have weakened
immune systems.
•Disseminated mucormycosis occurs when the infection spreads through
the bloodstream to affect another part of the body. The infection most
commonly affects the brain, but also can affect other organs such as the
spleen, heart, and skin.

28. Complications
•Brain Infarction and Hematoma after Hemorrhage
Vascular invasion is characteristic of rhinocerebral
mucormycosis
•Orbital Apex Syndrome
•Meningitis
•Brain Abscesses
•Garcin Syndrome
•Facial and Nasal Deformity
•Loss of vision

29. THANK YOU