A 55year-old male with uncontrolled diabetes mellitus presented with bilateral progressive nose block, anosmia, epistaxis and swelling over the left side of face of one month duration. There was a foul-smelling discharge from the left nostril.  He was on treatment elsewhere and the recent onset of nasal regurgitation of food prompted his visit to our OPD. There was no history of covid 19 infection or any other comorbidities.

On examination there was obvious asymmetry of the face with prominence of the left side of cheek. There was reduced sensation over the left nostril. On anterior rhinoscopy, the entire left nostril was filled with bloodstained debris.  Endoscopic examination revealed necrosed left inferior turbinate and anterior part of left middle turbinate with eroded medial wall of left maxillary sinuses. There was an oro-nasal fistula and there was no involvement of nasal septum.

Due to the absence of pain, on suctioning, the majority of the necrosed bone including the inferior turbinate was removed in the OPD setup itself (Figure 1).

A provisional diagnosis of invasive fungal sinusitis was made and the debris was sent for fungal staining and culture. Strict control of blood sugars was achieved.  Empirically liposomal amphotericin B was started at an initial dose of 1 mg/kg body weight per day and escalated to 3 mg/kg/day. Microbiological examination showed presence of nonstate ribbon-like hyphae suggestive of Mucormycosis.

Ct nose and Paranasal sinuses revealed involvement of entire left sided sinuses. It was abutting the left orbit without breach of lamina papyracea.  All walls of the left maxillary sinus were involved with nasal floor erosion. MRI showed the oronasal fistula and confirmed absence of orbital and intracranial involvement (Figure 2).

Patient was taken up for surgical debridement. For better precision navigation assisted image guided endoscopic surgery was done.  Modified Denker's approach was used and the floor of the left maxillary antrum was flushed with the nasal floor.  Complete surgical clearance of the disease was attained. Debridement was done till healthy bleeding tissue was reached. The repair of the oro-nasal fistula was planned as a second stage surgery.  Histopathological examination confirmed Mucormycosis (Figure 3).

Liposomal amphotericin B which was started earlier continued at a dose of 3 mg /kg body weight. Regular monitoring of renal function and other blood tests were done. Patient was started with saline nasal irrigation and weekly endoscopic suctioning.

After 3 weeks of intravenous liposomal amphotericin B, he developed a small whitish necrotic area near the anterior end of the nasal septum on the left side (Figure 4).

A punch biopsy of the doubtful area was taken and histopathology revealed Mucormycosis. This breakthrough infection prompted the use of second line antifungal therapy. We started with oral Posaconazole at a dose of 200 mg twice daily. The patient was clinically stable and discharged on oral Posaconazole. He reviewed every two weeks and after one month the cavity was cleared without any evidence of any recurrent disease. He continued the Posaconazole for another couple of weeks and then the drug was stopped. Now 5 months have been completed and he is in good condition. There is no asymmetry of face (Figure 5) and nasal endoscopy showed complete clearance without any fungal disease (Figure 6).