Outcomes of Open Fronto-Facial Resection for Fungal Osteomyelitis of Frontal Bone

Abstract

Introduction: The second wave of coronavirus disease 2019 (COVID-19) led to the resurgence of opportunistic infections due to the injudicious use of steroids. Sinonasal mucormycosis was declared an epidemic in India during the pandemic. Mucormycosis was managed effectively by surgical debridement along with systemic amphotericin B. Currently, a resurgence of mucormycosis following initial treatment, in the form of fungal osteomyelitis of the frontal bone, is being seen in India. Methods: This prospective study included 10 patients with fungal osteomyelitis of the frontal bone due to mucormycosis. All patients underwent surgical debridement of the sequestrum and involucrum, with systemic antifungal pharmacotherapy. Results: The average duration of time until mucormycosis recurrence was 22 days following initial treatment (range 10–33 days). Patients presented with extracranial bossing following outer frontal cortex erosion (n=3), bicortical erosion (n=3), bifrontal involvement (n=2), dural involvement (n=3), and involvement of the brain parenchyma and prefrontal cortex (n=2). All cases underwent debridement of the entire sequestrous bone and involucrum until normal bone could be identified. The mean admission duration was 4 weeks (range 3–6 weeks). All treated patients are currently alive and without disease, confirmed by contrast-enhanced computed tomography. Conclusion: Based on our experience, the successful treatment of fungal osteomyelitis due to mucormycosis requires a four-pronged approach: early detection, multidisciplinary management of comorbidities, surgical debridement of necrotic bone, and adequate systemic antifungal therapy.

Pott's puffy tumor: An unusual complication of rhino-orbito-cerebral mucormycosis

“…18 , 19 , 20 Significant cranial vault osteomyelitis secondary to ROCM was also seen, albeit less frequently. 7 , 8 , 9 , 12 , 13 , 21 , 22 However, presentation as PPT has been rarely described during either the pre-pandemic 6 or pandemic eras, 11 both publications being single case reports in adult patients.…”

“…Other series have described a craniotomy approach for similar cases. 7 , 8 , 9 Our own experience with 19 patients with ROCM and frontal osteomyelitis without PPT showed that there was no need to re-explore patients via either an open or endoscopic approach if the initial endoscopic debridement using a standard protocol was performed and followed up with antifungal therapy and regular cavity cleaning of the operated sinuses. We applied the same protocol for the management of patients with extensive skull base osteomyelitis too, with good outcomes.…”

“… 6 During the COVID-19 pandemic, however, a few cases of ROCM with frontal bone osteomyelitis were described, chiefly from India, where sinonasal mucormycosis had reached epidemic proportions. 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 As ROCM-PPT is an uncommon complication of sinonasal mucormycosis and the predisposing factors for this are unclear, we reviewed our records of patients with ROCM treated during the pandemic to analyze the clinicoradiological features and outcome of those patients diagnosed with ROCM-PPT to better understand the disease and its causative factors. To the best of our knowledge, this is the largest published series of patients with ROCM-PPT.…”