Retrospective Study of Rhino-Orbital Mucormycosis and its Management in a Tertiary Care Centre

Akshata Nagaral¹*, Sandesh Akki²

1 Department of ENT, MIMS, Mandya

2 Department of Orthopedics, MIMS, Mandya

*Correspondence: akshatasn15@gmail.com;

DOI: https://doi.org/10.71431/IJRPAS.2026.5411    

INTRODUCTION

The COVID-19 pandemic has spread across the globe, and research into patients with COVID-19 pneumonia, especially those with recurrent infections and comorbidities, is ongoing. Studies show that secondary infections are common among patients hospitalized for severe COVID-19, with approximately 10% to 30% of these patients affected. Fungal infections, in particular, appear to be significantly more prevalent, with rates up to ten times higher in this population. [1,2]

Rhino-cerebral mucormycosis, also known as Zygomycosis, is a rare but serious infection that impacts the nasal passages, paranasal sinuses, and brain. Caused by fungi from the Mucorales group within the Zygomycota phylum, it is an opportunistic infection that mainly affects individuals with conditions such as diabetic ketoacidosis, severe burns, organ transplants, prolonged steroid use, hemochromatosis, HIV, malnutrition, and hematologic cancers. [3,4] Mucormycosis, which starts in the nasal cavity and para nasal sinuses, extends to the palate, pharynx and orbits, producing facial and orbital pain, visual loss and swelling, generalized pain and headache due to the involvement of the sinuses. [5] Symptoms often include dark nasal discharge and black necrotic tissue in the nasal septum and turbinates and can progress paranasal sinusitis, sloughing of hard palate, orbital cellulitis, proptosis, ophthalmoplegia, and vision loss. [6,7]

Early detection and intervention are crucial for improving prognosis and reducing complications. Diagnosis can often be made through clinical evaluation and direct smears. Factors that contribute to better outcomes include early recognition, swift medical treatment, aggressive surgical intervention, and careful management of underlying health conditions. Survival rates for this condition vary, ranging from 20% to 70%, with some reports indicating mortality rates as high as 80%. [6,7]

To date, there is a lack of comprehensive Indian studies on a large scale that have explored the management of mucormycosis in the post-COVID period, highlighting a notable knowledge gap in this area. Here this article we explore 21 cases of rhinorbital mucormycosis, examining the clinical and demographic characteristics, treatment options, factors that influence prognosis, and overall outcomes.

MATERIALS AND METHODS

This retrospective study examines records of 21 inpatients admitted to the Department of Otorhinolaryngology in MIMS Mandya between April 2021 to July 2021. Inclusion criteria: Patients with KOH proven Rhino Orbital Mucormycosis. There are no Exclusion criteria

Patient selection criteria:

Diagnosis of Mucormycosis:

ROCM can be categorized as Possible, Probable, and Proven. A patient who has above mentioned symptoms and signs in the clinical setting of concurrent or recently (<6 weeks) treated COVID-19, diabetes mellitus, use of systemic corticosteroids and tocilizumab, mechanical ventilation, or supplemental oxygen is considered as Possible mucormycosis. When the clinical symptoms and signs are supported by diagnostic nasal endoscopy findings, or contrast-enhanced MRI or CT scan, the patient is considered as Probable mucormycosis. Clinico-radiological features, coupled with microbiological confirmation on direct microscopy or culture or histopathology with special stains or molecular diagnostics are essential to categorize a patient as Proven mucormycosis.[8]

Demographic and clinical information, including the presenting symptoms and findings from ear, nose, and throat examinations, as well as results from CT and MRI scans, were recorded. Treatment details were also documented using a specifically designed form. Patients were monitored for a period of nine months to evaluate any recurrence of the condition.

This study included 21 patients, with 7 females and 14 males (Table 1). The median duration from diagnosis to surgical intervention was six days. Nine patients (75%) were diagnosed with type II diabetes, and 2 patients (22%) had diabetic ketoacidosis. A combination of medical and surgical treatments was administered to 10 patients (83%), while 2 patients (17%) received medical treatment alone.

The treatment involved administering 5 mg/kg/day of liposomal amphotericin (L-AMB) by intravenous route. Renal function and blood electrolyte levels were monitored daily to detect any adverse reactions to the medication. The total dose of L-AMB ranged between 100 and 2000 mg. Common side effects included electrolyte imbalances and nephrotoxicity. However, to reduce the inflammation intravenous Inj Dexamethasone 20 mg for 5 days followed by 10mg for 5dyas was given.

Surgical procedures performed included endoscopic debridement, fronto-ethmoidectomy, middle meatal antrostomy, sphenoidotomy, maxillectomy to hard palate resection depending on the extension of the disease. Diseased mucosa with 1-2mm healthy mucosa was debrided to get clear surgical margins. Postoperative specimens were sent for fungal cultures and histopathological analysis. Upon discharge, patients were prescribed oral posaconazole tablets (400 mg daily in two divided doses) for 21 days, regardless of the severity of pain.

RESULT AND DISCUSSION

According to our research, the most likely affected are those with diabetes and post-COVID

periods. The most common signs and symptoms are facial pain and swelling (Graph 1). The disease spreads to the orbit and facial tissues, with the pterygopalatine fossa being the primary site of disease. The age range was between 61-80 years, and the male/female ratio is M:F = 2:1 (male -66.67% > female -33.33%) (Table 1).

Graph 1: Predominant symptoms of patients

Table 1: Distribution of patients according to Age and Sex

The two most prevalent predisposing factors identified in our study are diabetes mellitus and post-COVID status (Graph 2). In 4 of 21 patients, the deep region extended to the pterygopalatine fossa orbit, and the sinuses were the most frequently affected areas (32%) (Graph 3). All patients received intravenous amphotericin both before and after surgery, in addition to surgical debridement. 

Graph 2:  Distribution of patients according to predisposing factors.

Graph 3:  Distribution of patients according to the extent of disease

Table 2 shows distribution of mucormycosis patients associated with COVID-19 according to histopathological findings (Table 2). Necrosis was seen in about 85% of the patients followed by neutrophilic infiltration (76%), angioinvasion (62%) and granulomatous inflammation (47%).

Table 2: Distribution of patients according histopathological findings.

Out of the 21 patients, 18 received treatment along with endoscopic debridement (ED). Four patients underwent both endoscopic debridement and immediate maxillectomy, while the remaining four patients received endoscopic debridement followed by retrobulbar amphotericin injection. The overall mortality rate was 33%. Seven patients died due to complications such as refractory pneumonia, cardiac arrhythmias, and hypokalaemia.

Table 3: Correlation between Diabetic status and prognosis

The p-value is 0.0134. significant at p < 0.05.

Correlation was made between diabetic status and prognosis of the disease in Table 3 which showed, in uncontrolled diabetic patients disease had poor prognosis (mortality of 6 patients) compared to controlled diabetic patients who has good prognosis.The poor prognosis was primarily attributed to poorly controlled underlying conditions, such as diabetes.

However, surgical debridement is essential to achieve better results. The patient withmild disease survived withminimal surgical intervention and medical management, including orbital preservation. All patients were followed for a period of nine months and no recurrence was observed.

DISCUSSION:

The spread of the COVID-19 virus pandemic in India has led to an increase in mucormycosis, an infection that is extremely invasive and spreads quickly. Rather than using mycologic classification, the nomenclature for Mucormycosis is based on the localization of anatomic sites. There are three types of mucormycosis affecting the head and neck: isolated nasal, rhino-orbital, and rhino-orbital-cerebral. The saprophytic fungi Mucoraceae are often found in decaying matter and can be found in bread, soil, dust, and hospital wards. [9,10,11] Seasonal variance of the infection could theoretically be related to use of air conditioners. The organisms are potent in the temperate climates. [12]

Mucormycosis caused by Mucorales is one of the most life-threatening form of zygomycosis that occurs mainly in inmmunocompromised states, especially in diabetes mellitus, leukemia and lymphoma, COVID-19-induced immunomodulation, and the extensive use of steroids and oxygen therapy to treat severe COVID-19 are the causes of the increase in these cases. Despite their use Corticosteroids are well known to be associated with a myriad of adverse effects, including immunosuppression. By inhibiting transcription factors and affecting leukocyte function, prolonged corticosteroid use leads to significant CD4 lymphopenia and often a decrease in serum immunoglobulin (Ig)G. [13]

Normally, regulation of free iron in a host occurs by extremely effective iron sequesters such as transferrin, ferritin, and lactoferrin. The excessive glycosylation of transferrin and ferritin because of persistent hyperglycemia results in reduced iron affinity of these sequesters thereby releasing it in bloodstream and cells. This mechanism might form the basis for corticosteroids-induced hyperglycemia in COVID-19 patients increasing the susceptibility to mucormycosis. Therefore, host iron acquisition is crucial for the growth enhancement of Mucorales.[14]

Diagnosis is usually made by clinical features and histopathological findings; imaging is important in determining the degree of involvement. Early diagnosis and timely surgical intervention play a crucial role in managing the extent and severity of the disease. Our study's findings are consistent with previous research (Table 4), further contributing to the understanding of the epidemiology and clinical features of Rhino-Orbital Mucormycosis. In our study no residual disease was seen so role of radiotherapy in the mucormycosis was not study compared Talmi et al study where radiotherapy was considered for the residual disease.

Table 4: Comparison with other studies

The treatment of mucormycosis focuses on addressing the underlying cause, which can be challenging in COVID-19 patients who require high doses of steroids. The primary treatments include surgical debridement and the administration of amphotericin B. Since prognosis is influenced by multiple factors, early intervention is crucial. Once diagnosed, conservative treatment is typically started. Although orbital exenteration significantly impacts quality of life, it may be necessary in severe cases.

CONCLUSION

Rhino-orbital mucormycosis exhibits a variety of clinical symptoms and is seen more frequently in males. Key risk factors include post-COVID status and poorly controlled blood glucose levels. Early diagnosis using various diagnostic tools to evaluate disease severity is crucial for effective management. Survival rates have improved due to advancements in medical care and timely surgical intervention. Physicians should be aware of the potential for invasive fungal infections in COVID-19 patients. To reduce the risk of mucormycosis, it is recommended to carefully manage blood glucose levels and use steroids and antibiotics judiciously in COVID-19 patients.

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