Urgent Surgical Debridement
The next step is to pursue urgent surgical debridement immediately—this patient has rhino-orbito-cerebral mucormycosis with orbital extension, and surgical intervention combined with antifungal therapy is critical for survival and must not be delayed. 1
Why Immediate Surgery is Essential
Mortality reduction with combined therapy is dramatic. The evidence unequivocally demonstrates that patients receiving both antifungal therapy and surgical management have significantly higher survival rates compared to antifungal therapy alone (64.9% vs. 21.7%). 1 In advanced mucormycosis with orbital involvement, immediate and extensive surgical debridement reduces mortality from 67% to 39%. 1
Rhino-orbito-cerebral location demands aggressive local control. Surgery is of major importance specifically in rhino-orbito-cerebral mucormycosis, where the impact of local control on survival is striking. 1 This patient has the classic presentation: black eschar on the hard palate, maxillary sinus involvement with orbital extension, facial swelling, and periorbital edema—all indicating tissue necrosis requiring immediate debridement. 1
Delayed surgery doubles mortality. The 12-week mortality rate increases two-fold when treatment is deferred for 6 or more days from diagnosis, even with appropriate antifungal therapy. 1 Since liposomal amphotericin B has already been initiated, the surgical component cannot wait. 1
Why Other Options Are Inadequate
Repeat CT in 48 hours is inappropriate because this delays definitive treatment in a rapidly progressive, life-threatening infection where every day matters for survival. 1
Obtaining sinus cultures alone is insufficient as the diagnosis is already clinically established (black eschar is pathognomonic for mucormycosis), and waiting for cultures delays life-saving surgery. 1
Nasal endoscopy without immediate debridement may help visualize the extent of disease but does not address the necrotic tissue that must be removed urgently. 1
Surgical Approach
The debridement should be:
- Extensive and radical, removing all necrotic tissue including involved sinus mucosa, orbital contents if necessary, and any necrotic palatal tissue 1
- Performed urgently without delay once liposomal amphotericin B is started 1
- Conducted with appropriate infection control measures given the ICU setting 1
Concurrent Medical Management
While surgery proceeds, ensure:
- Liposomal amphotericin B at 5-10 mg/kg/day continues (10 mg/kg/day if CNS involvement develops) 1
- Aggressive glycemic control as poorly controlled diabetes is the primary risk factor 1
- Correction of DKA and metabolic derangements 1
Critical Pitfall to Avoid
Do not delay surgery to "see if antifungals work first." This is the most common error in mucormycosis management. The combination of immediate surgery plus antifungals is what saves lives—antifungals alone have a survival rate of only 21.7% compared to 64.9% with combined therapy. 1 The angioinvasive nature of mucormycosis means antifungals cannot adequately penetrate necrotic tissue, making surgical removal essential. 1