Mucormycosis progresses rapidly, resulting in cavernous sinus thrombosis, carotid artery occlusion, and central nervous system infarction secondary to fungal thrombosis 5-FU solubility dmso leading to hemiparesis, hemiplegia, coma, and death.11,12 Whenever there is a clinical suspicion of mucormycosis, sufficient biopsy material should be obtained from the affected area and examined for the characteristic fungal

appearance and specifically for the presence of fungal hyphae demonstrating vascular invasion, which clinches the diagnosis. Nasal scrapings and fine-needle aspiration cytology of paranasal masses can show fungal hyphae morphologically resembling Mucor giving a conclusive diagnosis of mucormycosis. Histological examination is considered more sensitive than cultures.13,14 There are four main approaches to the treatment of rhinocerebral mucormycosis. Reversing the underlying physiological predisposition. This involves the management of hyperglycaemia, electrolyte disturbance and acidosis. Discontinuing Bortezomib supplier any immunosuppressant

therapy and the use of growth colony-stimulating factor (GC-SF) which helps to reconstitute host defences. Systemic anti-fungal therapy with amphotericin B. The dose should be rapidly increased to achieve the highest possible tissue levels. Its use can be limited by its toxic effects on renal, cardiac and marrow tissues. Use of adjunctive therapies such as hyperbaric oxygen which helps to reduce tissue hypoxia and inhibits the growth of Phycomycetes and has been shown to give significant improvement in patients with low survival rates.15 Medical treatment alone does not favour a good prognosis. The mainstay of treatment is immediate aggressive surgical resection of the whole lesion – this should be performed without delay. The principle of effective surgical management is to debride thoroughly until one meets normal bleeding tissue. Patients may need repeated debridements. Both endoscopic and open techniques may need to be employed. Modalities include Caldwell-Luc, medial maxillectomy, ethmoidectomies, sphenoidectomies and even

radical maxillectomy with orbital exenteration.8 Wide excision should ideally occur before central nervous system encroachment.16,17 Owing to the rarity of mucormycosis, few substantial studies exist and there is understandably limited scope to enable through a direct randomised comparison of different treatment modalities. If the patient survives the initial presentation, the extent of the disease dictates additional inpatient care. Further surgical debridement, surgical repair, and wound care may be required.18 Post surgical disfigurement and visual impairment are both highly likely and provision of reconstructive surgery is required once it is clear the disease has been completely treated. Medical therapy needs to continue with tight glycaemic control, close monitoring for drug toxicity or recurrence of disease.