Results
A total of ten patients were admitted for recurrent frontal
osteomyelitis following initial treatment of covid associated sinonasal
mucormycosis. A total of eight patients (80%) were diagnosed with
recurrent Mucormycosis by KOH mount of pus from the frontal bone
osteomyelitis sent intraoperatively (Fungal elements/broad aseptate
hyphae). Nine patients were male (90%) and one female (10%). All the
patients (100%) had previously diagnosed sinonasal mucormycosis and
previous history of COVID 19 infection. 3 patients (30%) had previously
undergone orbital exenteration for CAM.
The average duration of the recurrence was 22 days following the initial
treatment Range (10 days to 33 days). The patients presented with
frontal headache (100%), frontal bulge (60%), discharging sinus near
the medial canthus (10%) (Figure -1), and fever (40%). The diagnostic
nasal endoscopy commonly revealed mucosalization of the nasal cavity
with mild polypoidal changes in the opened sinuses, there was evidence
of pus discharge from the frontal ostium in 30% cases and 40% cases
had frontal outflow tract obstruction. Retrospective radiographic review
of these patients showed partial to complete opacification frontal sinus
in 30% of cases during the initial disease presentation. 30% of
patients had undergone debridement of frontal sinus during the initial
surgery for CAM.
CECT scan was done to look at the bony status and a complimentary MRI
scan was done to look for the soft tissue extent (intraorbital, orbital
apex and intracranial extension) and as problem solving tool. The cross
sectional imaging revealed extracranial bossing following outer frontal
cortex erosion in 30% of cases (Figure -2), bicortical erosion in 30%,
bifrontal involvement (20%), Dural involvement (30%), brain
parenchymal involvement and prefrontal cortex (20%) case (Table -1).
Open surgical debridement was preferred due to recurrent nature of the
disease and for adequate disease clearance. Bifrontal craniotomy with
complete debridement of the frontal bone and pericranial flap was done
in 7 patients (70%), ipsilateral supraorbital craniotomy was done for 2
patients (20%), intraoperative CSF leak was seen in 2 patients (20%)
and was repaired by primary closure with onlay pericranial flap.
reconstruction with free flaps and alloplastic materials were not done
due to the possibility of seeding in the graft and foreign body
reaction. Frank pus was seen in all the patients after exteriorizing the
frontal sinus. Bony sequestrum and involucrum was seen along the frontal
bone in all the cases (Figure -3). Debridement entailed removal of
entire sequestrous bone and a part of involucrum till normal bone was
identified.
None of the patients had post operative CSF leak. A closed suction drain
was placed in the cavity, removed if drain was less than 25ml. Nasal
tamponade packing was removed on postoperatively following 48h.
No patients had neurological deficits following the surgery, 2 patients
had local wound collection which needed exploration and evacuation under
anaesthesia (Clavein Dindo Grade 3b). All the patients received
prophylactic broad spectrum antibiotic coverage and antifungal treatment
with Amphotericin B. Amphotericin B was continued till radiological
disease clearance. The mean duration of admission was 4 weeks (3 to 6
weeks). All treated patients are currently alive without disease,
confirmed by CECT.