Annals of Maxillofacial Surgery

EDITORIAL
Year
: 2021  |  Volume : 11  |  Issue : 1  |  Page : 1--2

Treatment algorithm for orofacial mucormycosis


SM Balaji 
 Department of Oral and Maxillofacial Surgery, Balaji Dental and Craniofacial Hospital, Chennai, Tamil Nadu, India

Correspondence Address:
S M Balaji
Department of Oral and Maxillofacial Surgery, Balaji Dental and Craniofacial Hospital, Chennai, Tamil Nadu
India




How to cite this article:
Balaji S M. Treatment algorithm for orofacial mucormycosis.Ann Maxillofac Surg 2021;11:1-2


How to cite this URL:
Balaji S M. Treatment algorithm for orofacial mucormycosis. Ann Maxillofac Surg [serial online] 2021 [cited 2021 Dec 1 ];11:1-2
Available from: https://www.amsjournal.com/text.asp?2021/11/1/1/322265


Full Text

[AUTHOR:1]

In the Indian second wave of the COVID-19 pandemic, India witnessed a huge number of infections per day, peaking in May 2021, with the country reporting more than 4 lakh cases per day. This led to serious medical emergencies in parts of the country, crushing the existing medical infrastructure. There was unprecedented demand for oxygen and medical supplies including Remdesivir. The emergence of new variants of COVID-19 and reduction in COVID-19 appropriate social behavior since February 2021 had possibly fuelled the second wave of COVID-19.[1],[2]

Also, in this wave, a large number of fungal infections were reported.[3],[4],[5],[6],[7] These infections, particularly mucormycosis, caused huge mortality and morbidity.[8] The cause for the spurt in fungal infections has been attributed to the use of steroids, possibility of altered blood sugar levels and persistently increased pro-inflammatory markers, such as IL-1, IL-6 and Tumour Necrosis Factor Alpha in COVID-19 patients. Also, they have relatively less CD4 interferon-gamma expression, fewer CD4 and CD8 cells. Though the cause is varied, there are numerous reports of these fungal infections. There are newspaper reports indicating more than 11,700 cases of mucormycosis alone in India during this second wave.[10] There has also been a report of non-availability of Amphotericin-B in certain parts of the country.

Irrespective of the conditions and forms, mucormycosis of the orofacial region presents as a swelling, painful ulcer or nodule of the jaw bones, sinus and noticeably at the gingiva. If left untreated or under-diagnosed, or late diagnosed, the lesion would undergo a rapid course, destroying all midfacial bone and probably invade the vascular channels to reach the orbit or lungs. When they reach these critical sites, removal of the eye or the affected organs are the only source of treatment.[11]

The treatment algorithm for orofacial mucormycosis is very simple. Early diagnosis is the key.[12],[13] Though antifungals such as Amphotericin-B are effective in controlling the spread of the disease, they cannot offer much relief to already infected and necrotized bone. In this situation, the only way to treat is aggressive debridement of the involved areas. Depending on the site – maxilla or mandible, fresh bleeding should be induced. Surgeon should not hesitate to remove dead and necrotic bone. When facing the crucial decision of saving certain parts for future reconstruction, surgeon should not hesitate to remove all offending and affected bone. Leaving back necrotized bone, though under antifungal cover, still predisposes to re-infection. Surgeons must consider the fact that there are plenty of options to recreate a critical sized defect of maxilla and mandible. They could rehabilitate the latter with advanced plates, grafts, and implants and other methodologies can be utilized to recreate lost form and function.[14],[15]

With the number of COVID-19 cases plummeting, the effect of the viral infection, known as long-term COVID-19 will soon manifest. Oral Surgeons should be ready to meet the wave of aggressive orofacial fungal infections and possible reconstruction. There might be some hesitancy among surgeons regarding the residual presence of such fungal organisms in the operation theatre. This can be eradicated by following proper operation theatre disinfection protocol.[16],[17]

The diagnosis and rehabilitation challenge in severe orofacial mucormycosis would be on the rise due to this second wave of COVID-19 and the oral surgeon community should shoulder the responsibility for early diagnosis, better treatment and later, appropriate reconstruction so that the quality of life would be better.

References

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