Outcome of Open Surgery in Disease Progression of Post-COVID Rhinomaxillary Mucormycosis Treated by Functional Endoscopic Sinus Surgery and Proposed Evaluation Scale for Maxillary Sinus Disease and Osteomyelitis

In this prospective clinical study, the cases (n = 17) were studied for the MSDO in Post-COVID mucormycosis clinically and from CT scans. There was a clinical improvement of clinical symptoms, all cases recovered clinically from symptoms of mucor infection in the maxillary sinus and bone. The CT-based comparison of pre-FESS, post-FESS shows the disease progression in maxillary bone and sinus. Similarly, CT comparison of post-FESS (CT2) and post-operative shows improvement in disease of maxillary sinus and bone in the given sample. This has proved statistically that the open method of debridement and removal of involved maxillary bone has given significant improvement clinically and on CT scans.

Histopathology, after open surgery showed fungal hyphae—broad, ribbon-like, irregular, and aseptate with branching at a right angle with haematoxylin and Eosin stain. This confirmed the progression of disease in the maxilla after closed endoscopic surgery. Epithelium, necrotic material, sequestrum, necrosed bone, inflammatory cells were seen in the section.

FESS replaced open surgical technique as the gold standard for the treatment of Chronic Maxillary Sinus diseases on account of its minimally invasive nature and physiological approach [6]. FESS is a conservative type surgery. The limitation of FESS in the management of MSD has been discussed in few articles. Despite many advances in endoscopic equipment and techniques. Richtsmeier WJ (2001) [7] have mentioned many indications for the Caldwell–Luc procedure, like removal of foreign bodies impacted in regions not visible or accessible with endoscopic instruments, removal of benign tumours, management of MO or osteoradionecrosis, exposure for orbital decompression, access to the pterygomaxillary space, repair of an oroantral fistula, and endoscopic surgical failures.

Forsgren K [8] in his study on rabbits mentioned that the Caldwell–Luc operation is still the mainstay of surgical treatment of maxillary sinus disease. Similar results were observed in the present study.

Chong et al. [9] in their article on FESS emphasized on ostiomeatal unit (OMU). FESS is based on the theory that the OMU is the key in the pathogenesis of chronic sinusitis. FESS aims to re-establish normal ventilation and sinus drainage. Advantages of FESS can be utilized if open and close methods can be done together. Whereas for drainage purpose nasal antrostomy is carried out in the inferior concha in open sinus surgery.

Singh et al. [10] mentioned that surgical debridement is very important for complete control of mucormycosis because antifungal agents cannot reach the involved site due to the blood vessel thrombosis. The diagnostic nasal endoscopy finding of white discoloration indicates tissue ischaemia which is secondary to angiocentric invasion. Spellberg B et al. [11] mentioned the common sites for mucormycosis, includes middle turbinate (67%), septum (24%), palate (19%), and inferior turbinate (10%). The change in the normal appearance of the nasal and the black necrotic eschar tissue with underlying purulent exudates with an unpleasant odour is the most consistent finding [12]. The pterygopalatine fossa acts as a reservoir for fungal disease. This area can only be approached by FESS [10].

In our cohort of seventeen patients with Rhinomaxillary Mucormycosis, FESS was not effective in control of disease, rather the disease increased and spread occurred after FESS. Whereas, this is the first study in post-COVID-19 maxillary mucormycosis establishing the importance of the open surgical method of Caldwell–Luc approach in maxillary sinus disease. Some studies have mentioned the limitations of FESS and the need for open surgery of Caldwell–Luc approach. FESS is essential for other paranasal sinus diseases. Hence, we recommend the use of open surgery if MSD due to mucormycosis is present in isolation. In cases of mucormycosis of other paranasal sinuses, the combined surgery of open method for maxillary sinus and FESS for other sinuses gives better clinical outcome and cure of mucor infection.

Contrast Paranasal CT scan is the main investigation which is for documentation of the presence of disease and demonstration of the exact spread and extent of the disease, especially for surgical management. Also, for demonstration of anatomical variations which consequently prevents surgical complications and aids in monitoring of disease and treatment [10].

Albu S et al. [13] mentioned that the extent of disease before surgery, as determined by CT scan, has a high correlation with FESS failure. The high level of severity of the disease of rhinomaxillary mucormycosis may be the reason for the progression of the disease after FESS surgery. This finding was corelating with our finding in this study.

Kende et al. [14] assessed the feasibility and limitations of functional endoscopic sinus surgery in combination with an intraoral open approach for the treatment of Chronic Maxillary Sinusitis of Dental Origin (CMSDO). They concluded that FESS with Caldwell–Luc approach should be considered as a part of the treatment of CMSDO for stable long-term results and minimal complications. We recommend use of open surgical approach for control of disease progression leading to osteomyelitis of maxilla.

In a case series (Six cases) of oro-nasal- paranasal sinuses mucormycosis reported that three cases responded to FESS with complete recovery. One case was treated with open debridement. IN FESS cases post-operatively nasal and antral douching with Amphotericin B was started with Oral Posaconazole. [Saidha et al.] [15]

In a retrospective study of thirty cases of Rhino-Orbito-Cerebral Mucormycosis, as a part of surgical intervention, Endoscopic Sinus Surgery (ESS) was done in twenty-seven patients; infrastructure maxillectomy [16] was done in two patients and subtotal maxillectomy for one patient. All patients responded to the timely diagnosis and debridement with the initiation of systemic amphotericin B. [17]

Yeo et al. reported a case of Rhinocerebral mucormycosis after functional endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps by endoscopic sinus surgery within four weeks. While in hospital, endoscopic debridement of the necrotic tissue and middle turbinectomy were performed. They discussed the unique point of this case that mucormycosis occurred after FESS. It is common to use antibiotics after FESS and oral or topical steroids may be used to reduce oedema intermittently. The main reason for the mucormycotic infection after FESS may have been the use of steroids or antibiotics after surgery which is a routine practice. [18]

Yadav et al. in the review article mentioned various surgical modalities for Rhino-orbital-cerebral mucormycosis. The endoscopic methods include Inferior turbinectomy, FESS (Functional endoscopic sinus surgery), Endoscopic decker’s approach, Mega-antrostomy, medial maxillectomy, Canine fossa puncture (CFP) technique. Open surgeries included Caldwell–Luc Operation, Nasomaxillary frame translocation in medial maxillectomy, Lateral rhinotomy, Weber Fergusson approach, Midfacial degloving approach. We used the open surgical approach [19]. Whereas, the endoscopic approach is an important and most commonly used surgical modality for all paranasal sinuses, our experience of the reported cases of recurrence of fungal infection indicates a word of caution. Thorough presurgical planning and use of combined open and close method approach may give a better result in aggressive fungal infections like mucormycosis.

MRI is the best imaging but its availability limits its use. We searched in literature for the CT-based evaluation scale for MSD. Lund-Mackay staging system is the most commonly used evaluation scale for paranasal sinuses. It has a limitation of scoring Maxillary sinus involvement as one unit. The disease in the maxillary sinus here is not scored in detail [20].

There is no CT-based grading system for maxillary osteomyelitis. Hence, we propose new evaluation scale for maxillary sinus disease and osteomyelitis. This proposed scale was used for the evaluation of the outcome of this study. The scoring here is a guide in deciding severity of disease, disease progression, planning the treatment of MSDO and outcome of surgery in post-operative phase after open surgical approach for management of MSDO.

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