Facial Nerve Palsy: An Unusual Presentation in Patients with Rhino Cerebral Mucormycosis

Facial Palsy in Post COVID-19 Invasive Fungal Sinusitis

This study aimed to study the various presentations of post COVID-19 invasive fungal sinusitis with 7th cranial nerve palsy and to correlate topodiagnostic tests and radiological findings to identify the site of lesion. A retrospective study was conducted at a tertiary care hospital where 11 patients with post COVID-19 invasive fungal sinusitis with facial palsy presented to our institute. Detailed history, clinical examination, radiological imaging were done for all patients. A total of 11 patients with post COVID-19 invasive fungal sinusitis with facial palsy were included in this study. The mean age of the patients was 44.8, with a male to female ratio of 4.5:1. Diabetes Mellitus was a major factor contributing to immunosuppression in our study with 9 patients who were known cases of diabetes mellitus and 2 newly diagnosed cases. On MRI, 10 patients had involvement of the Pterygopalatine fossa and 4 patients had involvement of the petrous apex. Post COVID-19 invasive fungal sinusitis can present with facial palsy, and diabetes mellitus is a major contributing factor to immunosuppression in these patients. The involvement of the petrous apex is a possible site of involvement, and MRI can aid in localizing the site of the lesion. Further studies are required to identify the exact mechanism of facial nerve palsy in invasive fungal sinusitis.

Rhinocerebral Mucormycosis with Extensive Cranial Nerve Palsies in a Diabetic Patient

Mucormycosis is a common opportunistic fungal infection with a disseminated nature. Despite being a devastating disease with the involvement of multiple upper cranial nerves, the implications of the seventh cranial nerve have been infrequently encountered. Although the radiological evidence with sinus destruction supports the diagnosis, histological specimen showing fungal elements confirms it as fungal culture doesn't always demonstrate a high diagnostic yield. Early detection and multimodal treatment are mandatory to prevent detrimental outcomes and to control the disease progression. We, hereby present a rare case of rhinocerebral mucormycosis with multiple cranial nerve involvement including the facial nerve in a 70-year-old female with long-standing poorly controlled diabetes mellitus.

Facial Nerve Palsy as Complication in COVID-19 Associated Mucormycosis: A Case Series

Mucormycosis is an opportunistic fungal infection indicating a high mortality rate. Among six varieties of involved sites, rhino cerebral mucormycosis (RCM) is not the most uncommon. During the COVID-19 pandemic, with the increase, in predisposing conditions incidence rate of mucormycosis progressed. For aggressive treatment, an early diagnosis can be armored to reduce morbidity and mortality. Clinically RCM poses non-specific symptoms and signs delaying diagnosis. This is associated with orbital cellulitis and sinusitis, one-sided headache behind the eye, diplopia, blurring of visions, nasal congestion, rhinorrhea, epistaxis, nasal hypoesthesia, facial pain and numbness, and a history of black nasal discharge. Not commonly the complications of cranial nerve involvement have been reported. In the present case series, three presentations of facial nerve palsy in COVID-19 associated with mucormycosis are added to the literature database.

Epidemiology, clinical features, therapeutic interventions and outcomes of mucormycosis in Shiraz: an 8-year retrospective case study with comparison between children and adults

Mucormycosis is an invasive fungal infection with high morbidity and mortality rate despite the early diagnosis and proper therapeutic interventions. Given the importance of epidemiological data in reviewing the attitude toward infectious diseases in developing countries, the current retrospective case study aimed to compare the epidemiological aspects, risk factors, clinical characteristics, therapeutic interventions, and outcomes of mucormycosis between adults and children during eight years (2013-2021) in the main infectious disease referral centers in the southwest of Iran. The median age of 164 patients included in this study was 47 years (IQR 22-59). The median length of hospitalization was 33 days.The annual incidence of mucormycosis-related hospitalizations was estimated 1.76 per 10,000 admissions during the study period. Moreover, the incidence of infection was 2.4 times higher in males than females in children. Diabetes mellitus was the most frequent predisposing factor in adults (46.0%). The main risk factor in children was hematologic malignancy (52.6%), but a considerable proportion of them (28.9%) were immunocompetent.The most frequent antifungal agent used was liposomal amphotericin B (82.3%) as monotherapy. The combination therapy was used more in adults (15.8%) than children (7.9%). In addition, surgical intervention with antifungal therapy was considered the most effective therapeutic approach. The in-hospital mortality rate was 14.6% for adults, whereas it was zero for children. Our findings provide a recent epidemiologic analysis of mucormycosis among hospitalized patients in both children and adults. Mucormycosis mainly affects individuals with diabetes mellitus or hematological malignancies and presents as rhino-orbito-cerebral form. Proven diagnosis of mucormycosis according to clinical manifestations and histopathology observations accompanied by proper antifungal treatments may improve survival rates.

Sublabial Approach Versus Modified Denker's Procedure: A Comparative Study of Pre-maxillary Tissue Clearance in Covid-Associated Mucormycosis

To compare the efficacy of the sublabial and modified Denker's procedure in clearance of fungal disease from the anterior wall of maxilla and the pre-maxillary area i.e. the difficult areas of maxillary sinus. A prospective observational study was conducted over a period of 2 months (April 21-June 21) in the ENT department of Sawai Man Singh hospital, Jaipur. All the patients with clinical involvement of the premaxilla or the cheek abutting the anterior wall of maxilla were included in the study population. Cases matched in both groups were subjected to debridement either by the sublabial or the modified denker's approach. Outcomes were measured by assessing the daily CRP values, post-operative DNE every 3 days after pack removal, and imaging at the end of 1 month. Repeat biopsies were performed in patients that still had persistent symptoms after getting operated on. 16 of the 60 patients (26.6%) operated on by the endoscopic approach showed evidence of residual disease on follow-up whereas only 5 patients (9.6%) in the other category had a similar outcome. Most of the recidivism was seen in the anterior maxilla. Lower rates of complications were found following debridement by the sublabial approach. Since the sublabial approach is the most direct approach for the key areas of fungal involvement of maxillary sinus, it is recommended over the modified Denker's procedure for disease clearance from pre maxilla and the anterior wall of maxillary sinus. This view is also supported by the lower rates of complications encountered following the former.

Complete and incomplete lower motor neuron facial palsy in post-COVID-19 mucormycosis

Purpose:

To study facial nerve palsy (FNP) in post-COVID-19-mucormycosis patients and its ocular complications, report different presentations of FNP in such patients, and propose its etiopathogenesis based on presentation and clinico-radiologic localization.

Methods:

A prospective cohort study was carried out in patients of post-COVID-19-mucormycosis who presented at our tertiary center, over a period of 3 months. Motor and sensory examination of the facial nerve was done to diagnose FNP and localize the lesion clinically. Slit-lamp examination was done for grading corneal involvement. MRI brain, orbit, and paranasal sinuses (PNS) with contrast were studied to find involvement along the facial nerve. It was assessed whether this site of lesion corresponded with clinical localization. Data were analyzed using the percentage of total cases and Fisher’s test.

Results:

A total of 300 patients with post-COVID-19 mucormycosis were examined, of which 30 (10%) patients were found to have FNP. All were lower motor neuron (LMN) type and were associated with corneal complications. The most common site clinically was distal to the chorda tympani (66.66%) and radiologically was infratemporal (IT) fossa (63.4%). The clinical localization significantly correlated with the radiological findings (P = 0.012). Twenty percent of patients showed incomplete involvement of facial muscles

Conclusion:

FNP was found to be of LMN type. The most common site of insult was IT fossa. There was a good clinico-radiological correspondence of lesions. Isolated lesions were also found along the peripheral nerve course, presenting as incomplete facial palsy. Recognition of FNP in post-COVID-19 mucormycosis, in all its variable forms, is important to manage corneal complications.

Facial neuritis in coronavirus disease 2019 associated mucormycosis: study on clinico-radiological correlates

Objective

To elucidate the aetiopathogenesis of facial neuritis in coronavirus disease 2019 associated mucormycosis.

Methods

A retrospective review was conducted of coronavirus disease 2019 associated mucormycosis patients who presented with peripheral facial nerve palsy from January 2021 to July 2021. The clinico-radiological details of four patients were assessed to examine the potential mechanism of facial nerve involvement.

Results

Serial radiological evaluation with contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging revealed infratemporal fossa involvement in all cases, with the inflammation extending along fascial planes to reach the stylomastoid foramen. Ascending neuritis with an enhancement of the facial nerve was demonstrated in all cases.

Conclusion

The likely explanation for facial palsy in patients with coronavirus disease 2019 associated mucormycosis, backed by radiology, is the disease abutting the facial nerve at the stylomastoid foramen and causing ascending neuritis of the facial nerve.

Intraoperative Scoring Assessment as a Prognostic Tool in Covid-19 Associated Mucormycosis: A Short-Term Observational Study

To introduce an intraoperative scoring system for covid-19 associatedmucormycosis An observational study conducted among 43 cases of confirmed CAM whichincluded 35 males and 8 females, with an average age of 56 years. The surgicalapproach adopted in our cases included endoscopic surgical debridement withDenker’s approach including mandatory pterygopalatine and infratemporal fossaexploration. All cases were intraoperatively scored using our designed intraoperativescoring assessment tool for mucormycosis. Postoperatively patient recovery wasassessed using C reactive protein levels and weekly imaging. Although an early observation in the post op period we observed highermortality among cases reporting with high scores as per our intraoperative reportingsystem. At the end of 2 months of completed treatment we report 6 cases of mortalityamong whom 5 cases were found to have scores (> 25) and one reported with a scoreof 18. This assessment helped us in grading the disease severity and also gaveus an insight about the postoperative prognosis too. Global scientific collaboration andreporting of a validated tool for CAM is of paramount importance to increase theknowledge with regard to this emerging disease.

Facial Nerve Palsy in COVID-19-Associated Mucormycosis Patients: A Case Series

Sinonasal mucormycosis is a deadly fungal illness that primarily affects diabetics who are uncontrolled. Numerous cranial nerves can be involved; however, facial nerve palsy has only been observed in a few cases. The main objective of this research is to highlight facial nerve involvement as a clinical sign of sinonasal mucormycosis. Nasal stuffiness, headaches, eye pain, orbital edema, ophthalmoplegia, and vision loss are common symptoms in these mucormycosis patients. The study was done in the Department of Otolaryngology & Head and Neck Surgery, All India Institute of Medical Sciences (AIIMS), Raipur, India. Nevertheless, 17 patients with facial nerve palsy (lower motor nerve palsy) and sinonasal mucormycosis arrived at our department. All patients were diabetic, and a majority of patients got Schirmer's test positive with severe stage. In the case of mucormycosis, facial nerve palsy is an unusual but noteworthy symptom. This could be misinterpreted as a cerebrovascular accident (CVA), causing the therapy to be delayed. This is critical as early identification, surgical debridement, and adequate therapy of the underlying metabolic imbalance, as well as amphotericin B, are critical for a successful treatment outcome in mucormycosis.

Facial Nerve Palsy with Total Ophthalmoplegia; a Novel Presentation of Fungal Invasion

Mucormycosis is an expeditious invasion of a fungus of angioinvasive nature, predominant in immunocompromised individuals, often leading to organ malfunction and loss. Facial nerve involvement and total ophthalmoplegia are its rare presentations. Early detection and treatment can alter natural disease course and prevent potential catastrophic outcomes in diabetic patients. Facial nerve palsy is mostly attributed to peripheral neuropathy in patients with advanced diabetes mellitus. It rarely raises alarm about an invasive fungal infection. Here, we report the case of a 38-year-old male with type 2 diabetes mellitus, who presented to us with left lower motor neuron type facial palsy and left-sided total ophthalmoplegia due to invasive rhino-orbito-cerebral mucormycosis (ROCM). Despite aggressive measures, including antifungal therapy and repeated endoscopic debridement, he subsequently developed central retinal artery occlusion (CRAO) and underwent left eye exenteration.

Epidemiology, clinical features, diagnosis and treatment of cerebral mucormycosis in diabetic patients: A systematic review of case reports and case series

BACKGROUND

Patients with diabetes are known as an important high-risk group for cerebral mucormycosis (CM).

METHOD

We conducted a structured search using PubMed/MEDLINE to collect both case reports and case series case (ie including at least two patients) onto CM in diabetic patient published between 2000 and March 2020.

RESULTS

Forty-five reports of individual cases and eighteen case series articles were included. India accounted for the largest share of reports with 37.7% and 38.8% of individual cases and case series, respectively. Mortality ranged from 0% to 100% in the case series. The overall mortality in the individual cases was 46.3%, and 64.2% of deaths were reported in patients with ketoacidosis diabetes. Facial swelling (53.3%), headache (44.4%), loss of vision (35.5%) and ophthalmoplegia (35.5%) were the most frequently reported clinical symptoms. In all patients except 4 (91.1%), CM was treated surgically; however, in many cases (42%), despite the use of surgery, death occurred. Amphotericin B deoxycholate (AMB) and lipid-based AMB (LAMB) were used as the first lines of treatment for all patients; however, posaconazole, echinocandins, hyperbaric oxygen therapy (HBOT) and deferasirox were used in combination for a number of patients. Posaconazole has been shown to have positive therapeutic effect; however, posaconazole, LAMB and HBOT are not commonly used in low-income and health-challenged countries.

CONCLUSION

Cerebral mucormycosis is a rapidly progressive infection in diabetic patients and carries immense morbidity despite early diagnosis and treatment. Low-income countries have had the highest number of reports of the disease in recent years, indicating the need to control diabetes in these countries.