Management of Post COVID 19 Mucormycosis with Osteomyelitis in The Maxilla, New Combined Consequences of The Pandemic. (Case Report).

ABSTRACT: Aim: This case report aims to demonstrate among health providers the importance of timely surgical and prosthetic management procedures of patients who suffered from the newly combined clinical entity of post COVID 19 mucormycosis and osteomyelitis of the palate. Materials and methods: Elaborate advanced diagnosis of the patients including CBCT, MRI, CT, Pathology examination, 3Ds printing reconstruction of the whole skull and digital design of reconstructive mesh that support the prosthesis were carried out. The patients undergone modified infrastructure maxillectomy and immediate prosthetic obturation of the palatal defect that was replaced later by a delayed obturator. Results: Surgical eradication of the necrotic bone and subsequent immediate obturation of the defect minimized morbidly and helped in improving the quality of life of these patients. Conclusion: Early diagnosis of this potentially fatal disease and reach-out a treatment plan immediately, is of prime importance in reducing the morbidly and mortality rate and enhance speech and eating in the two patients reported. It also decreases the psychological impact of this radical surgery

Fungal necrotizing fasciitis of face- a reconstructive challenge

Fungal necrotizing fasciitis (NF), particularly in the face, is an unusual infection. It is mostly seen in immunocompromised individuals and can be gravely destructive if diagnosis and treatment are delayed. We report this rare case of a 27-year-old, immunocompetent male who presented with gangrenous patch of skin on the cheek following blunt trauma to the right side of the face. Till now no case has been reported in literature with such an extensive soft tissue loss of face and involvement of facial skeleton due to fungal etiology. Clinical suspicion of necrotizing fasciitis led to early surgical intervention. Histopathological examination of the debrided tissue identified the infective organism as Apophysomyces elegans. Intravenous antifungal therapy with liposomal amphotericin B was initiated. Despite the prompt commencement of the treatment, the infection continued to spread, and the patient had to undergo serial debridement which resulted in orbital exenteration, partial maxillectomy and mandibulectomy on the right side. This resulted in a huge soft tissue defect requiring flap cover. A free anterolateral thigh flap was harvested to cover the soft tissue defect, but the blood flow could not be established. For salvage, scalp and pectoralis major muscle flaps were raised and used to cover the large hemifacial defect. The oral lining was created with a folded deltopectoral flap in a second stage. However, there was persistence of the fungal elements in wound bed even after prolonged systemic liposomal amphotericin B therapy and it invaded the flap margins due to which there was partial necrosis of the flap. In this article, we aim to describe the difficulties faced by us in the management of such devastating infection and the reconstructive challenge that it posed.

Mucormycosis of maxilla following tooth extraction in immunocompetent patients : reports and review

Mucormycosis is a rare, fulminant, rapidly spreading fungal infection, which usually affects patient with underlying immune deficiency. If not managed promptly, the disease is characterized by progressive necrosis and is often fatal. A review of English literature shows that only fourteen cases of mucormycosis have been reported after tooth extraction. This paper highlights two cases of mucormycosis subsequent to tooth extraction in healthy adult patients. This first patient presented with an oroantral fistula and extensive maxillary necrosis. Whereas the second case was localized and presented as non-healing extraction socket with alveolar necrosis. This adds two more cases of this rare and serious complication of tooth extraction, to the present literature

Challenges and Pitfalls in the Management of Rhino-Orbital Mucormycosis in Ophthalmology: A Highlighted Problem in the COVID-19 Era

Secondary infections in hospitalized and ill patients with coronavirus disease 2019 (COVID-19) are common. One of these life-threatening infectious diseases is rhino-orbital mucormycosis, which made an outbreak recently. This outbreak was mainly caused by the administration of high-dose corticosteroids in patients with COVID-19, especially those with diabetes mellitus. The increased incidence of rhino-orbital mucormycosis in the COVID-19 era presents different challenges for healthcare providers including ophthalmologists who are directly involved in disease management. We summarized the main challenges and recommendations for ophthalmologists on the management of rhino-orbital mucormycosis

Prosthodontic management of subtotal maxillectomy with minimally invasive interim obturator: a case report

The interim obturator serves as a pathway between the immediate or surgical obturator and the final prosthesis, offering functional and aesthetic benefits until the delivery of the definitive prosthesis. Furthermore, it acts as a guide during the fabrication of the definitive prosthesis, influencing aspects such as prosthesis extension, teeth arrangement, and the positioning of retentive aids. These aids may encompass orthodontic wiring, surgical suturing, and other non-invasive techniques. This case report details a conservative and less invasive method for retaining an interim obturator in maxillectomy patients, providing an alternative approach in prosthodontic care

Headache and Vision Loss as Initial Symptoms for an Acute Invasive Rhino-orbital-cerebral Mucormycosis

Background: Acute invasive rhino-orbital-cerebral mucormycosis (ROCM) is a rare fungal infection commonly caused by Rhizopus species. It occurs in immune- compromised individuals who have acquired immune deficiency syndrome (AIDS), leukemia, uncontrolled diabetes mellitus, or organ transplant patients who are on immunosuppressive therapy. Diagnosing invasive ROCM is challenging because its clinical presentation can be nonspecific, and it is not frequently observed in ophthalmic practices. Case Report: A 66-year-old Hispanic male with poorly controlled diabetes mellitus presented with the complaint of severe headache and retrobulbar pain in the right eye. An ophthalmic examination revealed normal ocular health in both eyes. Computerized tomography scan showed mild inflammatory mucosal thickening in the sinuses. Initially, he was diagnosed and treated for giant cell arteritis. The patient’s vision deteriorated to no light perception in the right eye with persistent 10 out of 10 headache and eye pain despite various treatments. Further evaluation revealed ROCM involving the sphenoid sinus. This was confirmed by a positive smear and culture of Rhizopus species from the sinus and from the patient’s symptoms improving with antifungal treatment. Conclusion: Sphenoid sinusitis is an unusual site of involvement with ROCM. The absence of nasal drainage adds to the difficulty of diagnosis without contrast imaging. Although rare, acute invasive ROCM should always be considered in any uncontrolled diabetic or immunosuppressed patient with acute headache and vision loss

A Simple Procedure for Oral Rehabilitation in a Complex Accident Injury: A Case Report

The use of a removable partial prosthesis is an effective treatment modality in the reconstruction of large maxillary defects, because it provides adequate support for the soft tissue and improves facial contours. Oral functions, such as speech and swallowing, also benefit from the use of removable partial prostheses. Osseointegrated implants are generally not indicated due to systemic factors, lack of bone anchorage, very long treatment times, and high costs. Therefore, the use of a removable partial prosthesis has been proposed as an alternative because of its relatively short treatment time, especially in patients undergoing successive bone- and soft tissue-grafting procedures. This report describes the use of an obturator prosthesis for the prosthetic rehabilitation of a maxillectomy patient with fractures due to a motorcycle accident

Micro Vascular Reconstruction of Maxilla using Free Fibula Flap

AIM: The purpose of the study was to evaluate the aesthetic and functional outcome after free fibula flap reconstruction for maxillary defects. OBJECTIVES: The long term outcome is evaluated in the following manner, 1. Fibula as a suitable reconstruction method for maxillary defects. 2. Patient satisfaction In terms of functional and aesthetic satisfaction at donor and recipient site. (annexure). 3. Wound infection and dehiscence. 4. Donor site morbidity. MATERIALS & METHODS: 3 patients were included in the study. Two patients were secondarily reconstructed due to post traumatic defect and mucormycosis, and third patient was primarily reconstructed after resection for squamous cell carcinoma. RESULTS: All the three patients had an improvement in speech and aesthetically acceptable results. One patient had wound dehiscence in the recipient site; one patient had pain in donor site for 3 weeks while walking downstairs. No difficulty in deglutition in any patients. CONCLUSION: Low donor site morbidity, acceptable aesthetic and functional outcome recommends micro vascularized free fibula flap to be considered as one of the ideal option for maxillary reconstruction. It improves the quality of life by improving the speech and swallowing

Surgical treatment of cocaine-induced palatal perforations : report of three cases and literature review

Destruction of the osteocartilaginous framework of the nose and sinuses is a well-known side effect of inhaled cocaine. Palate involvement is, however, a very uncommon event that may lead to oronasal communication with the subsequent food and liquids ref