Introduction
Mucormycosis is a fungal infection seen in individuals with weak immune system, with an upsurge of cases of COVID 19 a drastic increase in cases of ROMM is being witnessed at present. ROMM is seen due to 3 entities the agent, host, environment. Responsible factors are uncontrolled diabetes, overzealous usage of steroids, haemotological malignancies, antibiotics, post solid organ transplantation, usage of chemotherapeutic drugs, o2 therapy and ventilater etc. Mucormycosis is classified into 6 forms they are Rhinocerebral, Pulmonary, Cutaneous, Gastrointestinal, Disseminated, Uncommon types. ROMM has 80times highest incidence (0.14 per1000) in India, prevalence or mucormycosis varied from 0.005 to 1.7 per million population compared to other countries in recent estimare in 2019-2020. Injectable Liposomal amphotericin B and posaconazole oral antifungals and surgery are the treatment of choices. Mucor is also called as blackfungus because it causes tissue necrosis and any necrosed decomposed tissue produces eschar and that is colored black. Fungal hyphae have high effinity to internal elastic lamina of blood vessels, so they invade blood vessels and cause local tisse necrosis as well as thromboembolism and thrombotic infarcts. Skull base, cranial nerve and brain involvement carries grave prognosis. Patients attending to emergency department Gandhi hospital during the pandemic period of COVID 19 2nd wave with features of black fungus(ROMM) were selected and admitted in inpatients wards of ENT department from those patients symptoms with severe unilateral facial pain, and swelling,nasal crusting, nasal discharge, hyposmia, loose tooth, associated with co morbid conditions like diabetes and hypertention were selected in study (100patients)and sent them for CECT examination and DNE evaluation, both the findings are compared and from that patients who needs Endoscopic sinus surgery and ESS with maxillectomy, ESS with maxillectomy and orbital exentration were selected. Those patients evaluated by above said surgeries according to the patient need pre and post operatively liposomal amphotericin given during surgery involvement of turbinates with mucor (eschar/pus/necrosis) were seen along with sinuses involvement (maxillay, ethmoid.sphenoid, frontal), lamina, teeth, maxilla bone, hard palate, orbit etc., and results are taken in the study for most coomon and less common involvement of structures intraoperatively. And the involved structures(specimen) taken and sent for microbiological and pathological examination to see for commonest organism involved in mucormycosis in covid 19 positive cases. 1, 2, 3, 4, 5
Aim
To see the percentage of involvement of turbinates (IT,MT) in ROMM cases in COVID-19 positive patients by doing endoscopic sinus surgery and and ESS combind wih other procedures according to the need of patient. And to see the results by sending intra op specimen for microbiological and pathological examination.
Materials and Methods
A total number of 100 patients who were fit for sinus surgery and combind procedures (maxillectomy, orbital exentration) were selected from who are attending to emergency department of Gandhi hospital from a period April 2021 to September 2021(6 months). Patients were admitted and evaluated and taken into study.
Observations and Results
From the COVID 19 positive patients who are attended to Gandhi hospital emergency department with mucormycosis symptoms like nasal crusting, discharge, unilateral facial pain and swelling , with co morbid conditions like diabetes mellitus and hypertension were selected in study and sent for CECT examination and involvement of orbit, sinuses, maxilla bone, palate and teeth are confirmed and from them who are fit for surgery are taken for necessary procedures like ESS, ESS with maxillectomy, ESS with orbital exentration etc. And accordingly percentage of involvement of turbinates (IT,MT) are studied and results are summerised.
Table 1
Age Incidence
|
Group |
Age in Years |
No of Pts |
Percentage |
|
1 |
16-25 |
8 |
8% |
|
2 |
36-55 |
63 |
63% |
|
3 |
>55 |
29 |
29% |
Table 3
Symptomatology Index
|
Symptom |
No of Pts |
Percentage |
|
Unilaterfacialpain, swelling |
46 |
46% |
|
Dental Complaints |
34 |
34% |
|
Nasal Obstruction/crusting |
23 |
23% |
|
Nasal Sischarge |
22 |
22% |
|
hyposmia |
19 |
19% |
|
Blurring of vision |
6 |
6% |
Table 4
ENT Examination Index
|
Sign |
No of Pts |
Percentage |
|
Unilateral Peri Orbital Swelling |
63 |
63% |
|
Mobile Tooth |
30 |
30% |
|
DNS with Turbinate Hypertrophy |
20 |
20% |
|
Hard palate bulging |
11 |
11% |
|
CNS Involvement |
5 |
5% |
|
Skin Involvement |
2 |
2% |
Table 5
CECT findings
|
Site |
No of Pts |
Percentage |
|
Maxillary Sinus |
69 |
69% |
|
Ethmoid sinuses |
44 |
44% |
|
Sphenoid sinuses |
34 |
34% |
|
Orbits |
33 |
33% |
|
Turbinates |
20 |
20% |
|
Frontal Sinus |
12 |
12% |
|
Brain |
6 |
6% |
Table 6
Endoscopic sinus surgery findings
|
Structure Involved |
No of Pts |
Percentage |
|
Maxillary Sinuses |
58 |
58% |
|
Turbinates |
43 |
43% |
|
Ethmoid Sinuses |
37 |
37% |
|
Sphenoids |
11 |
11% |
|
Frontals |
2 |
2% |
Discussion
Rhino orbito cerebral mucormycosis is sudden unexpected disease due to over and counter usage of steroids and improper sterilization oxygen cylinders in COVID 19 positive cases during the era of phage 1 which was resulted in 2nd wave of COVID 19 pandemic with different types of diseases like ROMM. Patients attending to Gandhi hospital emergency in 6 months period with ROMM symptoms in COVID 19 positive cases 100 patients were selected and evaluation done by clinical, endoscopical and radiological based and taken for surgery results are tabulated according to the present study the results are out of 100 cases commonest age group is 36 to 55 years(63%), male sex predominance with 72 patients (72%), symptomatologically unilateral facial pain and swelling is common 46pts (46%), followed by dental complaints (34%), nasal obstruction (23%). On ENT local examination periorbital swelling in 63pts (63%), mobile teeth in 30pts (30%), DNS with turbinates hypertrophy in 20pts (20%), hard palate bulging in 11pts (11%), CECT findings showed changes in maxillary antra in 69 pts (69%), orbits (33%), ethmoids (44%), sphenoids (34%), turbinates (20%). After surgery FESS turbinates are 43%, maxillary antra 58%, ethmoids 37%, FESS with partial maxillectomy in 11pts (11%), total maxillectomy in 1pt,orbital exentration in 2pts(2%). KOH mount results showed positive in 72 pts (72%), HPE of intraoperative specimen showed mucorales order in 58pts(58%), rhizopus species in 16pts(16%), aspergillus 6pts(6%), at the end of this study accuracy of turbinate (MT) involvement in mucor cases is more common along with maxillary sinus and middle meatus. when compare to orbit, dental and maxilla bone. Frontal sinus and CNS involvement is rare as per this study. 6, 7
Conclusion
Main conclusions of this study are male gender predominance, 36to 55 years common age, unilateral facial pain and swelling is common symptom, maxillary sinus is the commonest sinus to be involved, mucorales is the common order of fungi, diabetes is the commonest co morbid condition, turbinates most commonly middle turbinate along with maxillary sinus and middle meatus are more involved in ROMM as per this study.
