Table Of ContentRhino-Orbito-
Cerebral
Mucormycosis
Nishi Gupta
Santhosh G. Honavar
Editors
123
Rhino-Orbito-Cerebral Mucormycosis
Nishi Gupta • Santhosh G. Honavar
Editors
Rhino-Orbito-Cerebral
Mucormycosis
Editors
Nishi Gupta Santhosh G. Honavar
Department of Otorhinolaryngology Department of Ophthalmic Plastic
& Head & Neck Surgery Surgery and Orbital Diseases
Dr Shroff Charity Eye Hospital Centre for Sight, Banjara Hills
Daryaganj, Delhi, India Hyderabad, India
ISBN 978-981-16-9728-9 ISBN 978-981-16-9729-6 (eBook)
https://doi.org/10.1007/978-981-16-9729-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
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Dedicated to all those who have perished as a result of this dreadful
disease, as well as the families who have borne the anguish of mutilating
treatments on their loved ones while staying strong.
Foreword
This book authored and edited by Drs Nishi Gupta and Santhosh Honavar
provides invaluable information on Rhino-Orbital-Cerebral Mucormycosis
(ROCM). Not commonly encountered in most developed countries, ROCM
labelled as “Black Fungus” made headlines all over the world, as it blazed,
fast and furious, through the sub-continent of India, creating an avalanche of
cases, during the second wave of Covid-19 pandemic, that took place for
several months in 2021. Almost 50000 cases were reported in three months
ending July 2021.
This book is a compilation of personal and institutional experiences of
several authors who risked their lives to fight this deadly disease. The chal-
lenges faced were insurmountable, but they fought valiantly. The battle is far
from over and the fight against Covid-19 related mucormycosis continues.
The large number of cases led to a better understanding of this disease and
its management which is expressed in this book. Each individual chapter pro-
vides invaluable up-to-date information on all aspects of ROCM including
aetiology, pathophysiology, clinical behaviour, clinical features, diagnostic
modalities, histopathology and treatment.
A debate on classification and prognostic guidance for ROCM has also
been proposed. All chapters are accompanied with images and illustrations to
provide for a better understanding. As an example, the chapter on histopathol-
vii
viii Foreword
ogy is accompanied with excellent pictures showing some rarely seen histo-
logical features.
The vital role of imaging, such as computed tomography (CT) scan, mag-
netic resonance imaging (MRI) and its various sequences, such as DWI, T1,
T2, STIR, FLAIR, CISS and FIESTA, in making an early diagnosis, assess-
ment of the extent of the disease, staging and surgical planning and subse-
quent follow-up evaluation has been well discussed.
The chapters on treatment, including medical treatment ranging from tra-
ditional Amphotericin to newer Azoles and adjunctive treatments are very
well written. The pharmacodynamics, dosage and methods on administration
and their role in the management of ROCM are discussed and easy to
understand.
Surgical debridement of ROCM is, undoubtedly, challenging. Familiarity
to how it spreads and the anatomical regions involved, guided by imaging
studies, is the key to surgical debridement. This can be achieved both by
endo-nasal and open approaches. Indications for surgery, both endo-nasal and
open approaches have been discussed and illustrated by several case reports,
in this book.
Each article has several learning points and clinical pearls to offer. These
collectively become a treasure trove of information for physicians and sur-
geons interested in this disease. My congratulations to all the contributors for
an excellent work!
Dharambir S. Sethi
NUS-Duke Graduate Medical School, Singapore, Singapore
Novena ENT – Head & Neck Surgery Centre, Singapore, Singapore
Preface
There was a definite goal in mind when developing a textbook on Rhino-
Orbito-Cerebral Mucormycosis (ROCM) at the time. The desire evolved as a
result of a dreadful disease that claimed the lives of those who were impacted
by it.
The unexpected surge in cases, the disease’s aggressiveness, its unpredict-
able course, and acute shortages of pharmaceuticals and equipment accesso-
ries made it seem as if the entire universe had come down to put our endurance,
talent, and courage to the test in the face of this unique situation.
Every day was a new learning experience, with new approaches being
investigated and discoveries being documented and compared. In summary,
every effort was made to pick up as soon as feasible and to save as much as
possible. As a result of this, several forums with all of the essential skills to
treat ROCM were developed.
This book captures the essence of all we learnt during the outbreak.
Pathogenesis, diagnosis, and an emphasis on culture-independent diagnostic
techniques, as well as required surgical processes and specific advancements,
are all presented. As a result of our interactions with those patients, several
debates have erupted on a variety of topics. This publication was written with
the help of clinicians from several specialties. The topic of future directions
was explored. Invasive fungal diseases, particularly in rhino-orbito-cerebral
areas, require much greater attention.
Daryaganj, Delhi, India Nishi Gupta
Hyderabad, India Santhosh G. Honavar
ix
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Nishi Gupta
2 Clinical Presentation of Cases with Rhino-Orbito-Cerebral
Mucormycosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Nidhi Dhawan and Nishi Gupta
3 Imaging in Rhino-Orbito-Cerebral Mucormycosis (ROCM) . . . 13
Bavaharan Rajalingam
4 Pathogenesis of COVID-Associated Mucormycosis . . . . . . . . . . . 39
Shreya Singh, Rimjhim Kanaujia,
and Shivaprakash M. Rudramurthy
5 Microbiological Diagnosis of Rhino-Orbito-Cerebral
Mucormycosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Harsimran Kaur, Parakriti Gupta,
and Shivaprakash M. Rudramurthy
6 Histopathological Diagnosis of Rhino-Orbito-Cerebral
Mucormycosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Aanchal Kakkar and Kavneet Kaur
7 Surgical Management of Rhino- Orbito- Cerebral
Mucormycosis: Basic Endoscopic Sinus Surgery Procedures . . 79
Nishi Gupta, Poonam Singla, Nidhi Dhawan, and Sonil Jain
8 Surgical Management of Rhino- Orbito- Cerebral
Mucormycosis (ROCM); Approach to Pterygopalatine Fossa,
Pterygoid Process, Infratemporal Fossa, and Orbit . . . . . . . . . . 95
Nishi Gupta
9 Surgical Management of Rhino- Orbito- Cerebral
Mucormycosis; Drilling Beyond Sinuses
in Rhino- Orbito- Cerebral Mucormycosis . . . . . . . . . . . . . . . . . . 109
Satish Jain and Nishi Gupta
10 Globe Sparing Transnasal Endoscopic Orbital Exenteration
in Rhino-Orbito-Cerebral Mucormycosis . . . . . . . . . . . . . . . . . . 119
Satish Jain and Nishi Gupta
xi
xii Contents
11 Open Surgery in Rhino-Orbito- Cerebral Mucormycosis . . . . . . 137
Hitesh Verma and Kapil Sikka
12 Cranio-Cerebral Mucormycosis . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Ravisankar Manogaran, Arulalan Mathialagan, Amit Keshri,
Govind Bhuskute, Ashutosh Kumar, Arun Srivastava,
Rungmei S. K. Marak, and Sanjay Behari
13 Palatal Disease in Rhino-Orbito-C erebral Mucormycosis . . . . . 165
Aditya Moorthy and Tulasi Nayak
14 Lacrimal Drainage System in Rhino-Orbito-Cerebral
Mucormycosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Nishi Gupta, Rafal Nowak, and Shreya Aggarwal
15 Antifungal Therapy in Rhino- Orbito- Cerebral
Mucormycosis (ROCM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Rajeev Soman and Sujata Rege
16 Medical Management of Patients with
Rhino-Orbito-Cerebral Mucormycosis . . . . . . . . . . . . . . . . . . . . . 203
Bhushan S. Bansal
17 Clinical Profile and Management of a Series
of Rhino-Orbital-Cerebral Mucormycosis Cases at
Otorhinolaryngology Department of a Tertiary Hospital . . . . . . 209
Madhuri Mehta, Priyanka Chhabra, and Akanksha Jain
18 Analysis of Orbital Involvement in 562 Cases
of Rhino-Orbito-Cerebral Mucormycosis . . . . . . . . . . . . . . . . . . 251
Mohnish Grover, Tanmaya Kataria, and Madhav Goel
19 Decision-Making in Orbital Mucormycosis: Conservative
Versus Orbital Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Santhosh G. Honavar and Rolika Bansal
20 Debates in Rhino-Orbito Cerebral Mucormycosis (ROCM):
Classification Dilemmas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Nishi Gupta, Satish Jain, and Poonam Singla
21 Debates in Rhino-Orbito-Cerebral Mucormycosis: Orbital
Disease Management Dilemma . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Nishi Gupta, Satish Jain, and Poonam Singla
22 Profile of Rhino-Orbito-Cerebral Mucormycosis
Patients Reporting after Multiple Debridement
and Antifungal Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Nishi Gupta, Shruti Ogra, and Shreya Aggarwal
23 Future Directions in the Management
of Rhino- Orbito- Cerebral Mucormycosis . . . . . . . . . . . . . . . . . . 297
Nishi Gupta
