case_images: PMC10953642_01
case_images: Black arrow: oroantral fistula in the hard palate, white arrow: loss of teeth. HP: hard palate.
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case_images: PMC10953642_01_rpmesp-40-01-11980-g001.jpg
case_images: f1
case_images: On physical examination, she presented left oroantral fistula with purulent discharge (Figure 1).
case_images: Case 1. Left nasal endoscopy. (A) Admission endoscopy (B) Endoscopy during standard treatment. (C) Endoscopy after 30 sessions of treatment with adjuvant hyperbaric oxygen. Facial CT scan. (D) On admission, hypertrophy of the mucosa of the left maxillary sinus, bone lysis of its medial and inferior wall and palatine bone. Obstruction of the left ostiomeatal complex. (E) CT scan during standard treatment. (F) Tomographic control after 30 sessions of treatment with adjuvant hyperbaric oxygen, shows improvement of the nasal mucosa and oroantral fistula. Asterisk: posterior wall of maxillary sinus, Co: choana, S: septum, IT: inferior turbinate, MT: middle turbinate; dashed black arrow: devitalized bone tissue, white arrowhead: scar mucosa, continuous black arrow: granulation tissue.
case_images: rpmesp-40-01-11980-g002.jpg
case_images: PMC10953642_01_rpmesp-40-01-11980-g002.jpg
case_images: f2
case_images: Nasal endoscopic and tomographic evaluation happened at three points in time: at the beginning of conventional treatment, 35 days after initiation of ST and after 30 sessions of HBOT (Figure 2). Nasal endoscopy evidenced necrosis of bone tissue in the posterior wall of the left maxillary sinus in addition to purulent discharge at baseline ST (Figure 2A). The inferior and middle turbinate were absent at day 35 of ST, with polypoid-like tissue formation and persistent discharge (Figure 2B). Thirty sessions of HBOT were added after day 35 of ST, after which the sinus mucosa improved with scar-like tissue and granulation without purulent content or necrosis at endoscopy (Figure 2C). Computed tomography (CT) of the paranasal sinuses on admission showed findings compatible with mucormycosis in the left maxillary sinus and palatine bone (Figure 2D). After 30 sessions of HBOT, the tomographic images improved significantly (Figures 2D, 2E and 2F). But endoscopic-tomographic evaluation after ST showed that the disease persisted (Figures 2B, 2E).
case_images: (A) case 1, (B) case 2. Nasosinusal mucosa with Hematoxylin-Eosin staining. (C) case 2. Nasal mucosa with Grocott's methenamine silver stain at 40X showing wide ribbon-like pauciseptate hyphae, some of them deformed (thick black arrow), others with branching (thin black arrow) and areas of necrosis.
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case_images: PMC10953642_02_rpmesp-40-01-11980-g004.jpg
case_images: f4
case_images: Histologic examination of the left maxillary sinus mucosa with hematoxylin eosin and Grocott-Gomori methenamine silver staining showed mucor hyphae (Figures 4B and 4C), which confirmed the diagnosis of mucormycosis.
case_images: PMC10953642_02
case_images: Case 2. Left nasal endoscopy. (A) Endoscopy on admission. (B) Endoscopy during standard treatment. (C) Endoscopy after 30 sessions of treatment with adjuvant hyperbaric oxygen. (D) Facial CT scan. On admission, mucosal hypertrophy of the left maxillary sinus, occupation of anterior ethmoid cells and dehiscence of the orbital floor. (E) CT scan during standard treatment. (F) Tomographic control after 30 sessions of treatment with adjuvant hyperbaric oxygen showing decreased mucosal thickening and a left oroantral fistula. Continuous black arrow: necrotic crusts, dashed black arrow: cerebrospinal fluid fistula, black arrowheads: septal perforation margin. S: septum, IT: inferior turbinate, MT: middle turbinate, SS: sphenoid sinus, Co: choana.
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case_images: PMC10953642_02_rpmesp-40-01-11980-g003.jpg
case_images: f3
case_images: Nasal endoscopy on admission showed necrotic crusts (Figure 3A). A CT of the paranasal sinuses showed signs compatible with mucormycosis in the maxillary sinus, ethmoid and left sphenoid sinus (Figure 3D). Nasal endoscopy revealed a cerebrospinal fluid fistula in the roof of the left anterior portion of the ethmoid bone as well as necrosis of the nasal attic mucosa (Figure 3B). Endoscopic and tomographic improvement was evident after HBOT (Figures 3C, 3F).
case_images: (A) case 1, (B) case 2. Nasosinusal mucosa with Hematoxylin-Eosin staining. (C) case 2. Nasal mucosa with Grocott's methenamine silver stain at 40X showing wide ribbon-like pauciseptate hyphae, some of them deformed (thick black arrow), others with branching (thin black arrow) and areas of necrosis.
case_images: rpmesp-40-01-11980-g004.jpg
case_images: PMC10953642_02_rpmesp-40-01-11980-g004.jpg
case_images: f4
case_images: Histologic examination of the left maxillary sinus mucosa with hematoxylin eosin and Grocott-Gomori methenamine silver staining showed mucor hyphae (Figures 4B and 4C), which confirmed the diagnosis of mucormycosis.