Rhino orbital cerebral mucormycosis

Rhino orbital cerebral mucormycosis

Rhino orbital cerebral mucormycosis rapidly became an epidemic following the COVID-19 pandemic 1)

Gutiérrez-Delgado et al searched PubMed database from 1964 to 2014 for all available articles in the English language related to rhino-orbital-cerebral chronic infections caused by fungi of the order Mucorales and found 22 cases 2).

Rhino-orbital-cerebral mucormycosis is usually associated with a poor prognosis and is almost exclusively seen in immunocompromised patients

2015

A unique case of isolated intracranial mucormycosis of a slowly progressive nature in a healthy immunocompetent child. A 4-year-old girl with a clear medical and surgical history presented with complaints of right side facial asymmetry and unsteady gait for a period of 10 months. Clinical and radiographic investigations revealed right-sided lower motor neuron facial palsy caused by an infiltrative lesion on the right cerebellopontine angle. Initial surgical debulking was performed, a biopsy was sent for histopathological examination, and a course of prophylactic antibiotic and antifungal drugs was prescribed. The pathological report confirmed the mucormycosis fungal infection, and intravenous amphotericin B was administered for 3 weeks. One month after admission, the patient left the hospital with complete recovery. Follow-ups after 4, 8 and 12 weeks revealed no sensory or motor neurological deficits. In conclusion, this is a unique case of mucormycosis with regard to the nature and location of the infection, along with the host being a healthy child. Initial surgical exploration is a very critical step in the early diagnosis and treatment of such rare conditions 3).

2014

A 42-year-old man who developed a cerebellar mucor abscess after undergoing hematopoietic stem cell transplant for the treatment of myelodysplastic syndrome. In the post-operative period he was admitted to the neurocritical care unit and received liposomal amphotericin B intravenously and through an external ventricular drain. This patient demonstrates that utilization of an external ventricular drain for intrathecal antifungal therapy in the post-operative period may warrant further study in patients with difficult to treat intracranial fungal abscesses 4).

2013

A case of mucormycosis presenting with extensive necrosis of the maxilla with extension into the retrobulbar and infrabulbar region in an otherwise healthy patient. He underwent extensive debriding surgery followed by amphotericin B first and then oral antifungal therapy, but unfortunately, even after extensive surgery and medical treatment, he did not survive 5).

2010

Yoon et al describe a case of Rhino-orbital-cerebral (ROC) mucormycosis with pericranial abscess occurring in a female patient with uncontrolled diabetes mellitus. The infection initially developed in the right-sided nasal sinus and later progressed through the paranasal sinuses with the invasion of the peri-orbital and frontotemporal region, due to the delayed diagnosis and treatment. Numerous non-septate hyphae of the zygomycetes were identified by a punch biopsy from the nasal cavity and by an open biopsy of the involved dura. The patient was treated successfully with extensive debridement of her necrotic skull and surrounding tissues, drainage of her pericranial abscess and antifungal therapy, including intravenous amphotericin B for 61 days and oral posaconazole for the following 26 days. She returned to a normal life and has had no recurrence since the end of her treatment 15 months ago 6).

2000

A 59-year-old immunocompetent white man sustained a high-pressure water jet injury to the right inner canthus while cleaning an air conditioner filter. He later had “orbital cellulitis” develop that did not respond to antibiotics and progressed to orbital infarction. Imaging studies and biopsy results led to a diagnosis of mucormycosis. Tissue culture grew Apophysomyces elegans, a new genus of the family Mucoraceae first isolated in 1979. Orbital exenteration and radical debridement of involved adjacent structures, combined with intravenous liposomal amphotericin, resulted in patient survival.

After orbital exenteration and debridement of involved adjacent structures along with intravenous liposomal amphotericin, our patient has remained free from relapse with long-term follow-up.

The agent causing this case of rhino-orbital-cerebral mucormycosis (Apophysomyces elegans) contrasts with the three genera most commonly responsible for mucormycosis (Rhizopus, Mucor, and Absidia) in that infections with this agent tend to occur in warm climates, by means of traumatic inoculation, and in immunocompetent patients. Rhino-orbital-cerebral mucormycosis should be considered in all patients with orbital inflammation associated with multiple cranial nerve palsies and retinal or orbital infarction, regardless of their immunologic status. A team approach to management is recommended for early, appropriate surgery and systemic antifungal agents 7).


1)

Soni K, Das A, Sharma V, Goyal A, Choudhury B, Chugh A, Kumar D, Yadav T, Jain V, Agarwal A, Garg M, Bhatnagar K, Elhence P, Bhatia PK, Garg MK, Misra S. Surgical & medical management of ROCM (Rhino-orbito-cerebral mucormycosis) epidemic in COVID-19 era and its outcomes – a tertiary care center experience. J Mycol Med. 2021 Dec 25;32(2):101238. doi: 10.1016/j.mycmed.2021.101238. Epub ahead of print. PMID: 34979299.
2)

Gutiérrez-Delgado EM, Treviño-González JL, Montemayor-Alatorre A, Ceceñas-Falcón LA, Ruiz-Holguín E, Andrade-Vázquez CJ, Lara-Medrano R, Ramos-Jiménez J. Chronic rhino-orbito-cerebral mucormycosis: A case report and review of the literature. Ann Med Surg (Lond). 2016 Feb 6;6:87-91. doi: 10.1016/j.amsu.2016.02.003. eCollection 2016 Mar. PubMed PMID: 26981237; PubMed Central PMCID: PMC4776268.
3)

Al Barbarawi MM, Allouh MZ. Successful Management of a Unique Condition of Isolated Intracranial Mucormycosis in an Immunocompetent Child. Pediatr Neurosurg. 2015;50(3):165-7. doi: 10.1159/000381750. Epub 2015 May 7. PubMed PMID: 25967858.
4)

Grannan BL, Yanamadala V, Venteicher AS, Walcott BP, Barr JC. Use of external ventriculostomy and intrathecal anti-fungal treatment in cerebral mucormycotic abscess. J Clin Neurosci. 2014 Oct;21(10):1819-21. doi: 10.1016/j.jocn.2014.01.008. Epub 2014 May 19. Review. PubMed PMID: 24852901.
5)

Rahman A, Akter K, Hossain S, Rashid HU. Rhino-orbital mucourmycosis in a non-immunocompromised patient. BMJ Case Rep. 2013 Feb 6;2013. pii: bcr2012007863. doi: 10.1136/bcr-2012-007863. PubMed PMID: 23391952; PubMed Central PMCID: PMC3604437.
6)

Yoon YK, Kim MJ, Chung YG, Shin IY. Successful treatment of a case with rhino-orbital-cerebral mucormycosis by the combination of neurosurgical intervention and the sequential use of amphotericin B and posaconazole. J Korean Neurosurg Soc. 2010 Jan;47(1):74-7. doi: 10.3340/jkns.2010.47.1.74. Epub 2010 Jan 31. PubMed PMID: 20157385; PubMed Central PMCID: PMC2817523.
7)

Fairley C, Sullivan TJ, Bartley P, Allworth T, Lewandowski R. Survival after rhino-orbital-cerebral mucormycosis in an immunocompetent patient. Ophthalmology. 2000 Mar;107(3):555-8. PubMed PMID: 10711895.

Relative value units

Relative value units

Relative value units (RVUs) were designed to provide relative economic values for medical care based on the cost of providing services categorized as a physician work, practice expense, and professional liability. … RVUs were designed to provide a rational approach to assessing the relative value of medical services.


The debate surrounding the integration of value in healthcare delivery and reimbursement reform has centered around integrating quality metrics into the current fee-for-service relative value units (RVU) payment model. Although a great amount of literature has been published on the creation and utilization of the RVU, there remains a dearth of information on how clinicians from various specialties view RVU and the quality-of-care metric in the compensation formula. The aim of a review was to analyze and consolidate existing theories on the RVU payment model in neurosurgery. Google and PubMed were searched for English-language literature describing opinions on the RVU in neurosurgery. The commentary was noted to be primary opinions if it was mentioned at least twice in the eight articles included in this review. Overall, seven primary opinions on the RVU were identified across the analyzed articles. Integration of quality into the RVU is viewed favorably by neurosurgeons with a few caveats and opportunities for further improvement 1).


The work relative value unit (wRVU) is a commonly cited surrogate for surgical complexity; however, it is highly susceptible to subjective interpretation and external forces.


The objective of Kim et al. was to evaluate whether wRVU is associated with perioperative outcomes, including complications, after brain tumor surgery. The 2006-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients ≥ 18 years who underwent brain tumor resection. Patients were categorized into approximate quintiles based on total wRVU. The relationship between wRVU and several perioperative outcomes was assessed with univariate and multivariate analyses. Subgroup analyses were performed using a Current Procedural Terminology code common to all wRVU groups. The 16,884 patients were categorized into wRVU ranges 0-30.83 (4664 patients), 30.84-34.58 (2548 patients), 34.59-38.04 (3147 patients), 38.05-45.38 (3173 patients), and ≥ 45.39 (3352 patients). In multivariate logistic regression analysis, increasing wRVU did not predict more 30-day postoperative complications, except respiratory complications and need for blood transfusion. Linear regression analysis showed that wRVU was poorly correlated with operative duration and length of stay. On multivariate analysis of the craniectomy subgroup, wRVU was not associated with overall or respiratory complications. The highest wRVU group was still associated with greater risk of requiring blood transfusion (OR 3.01, p < 0.001). Increasing wRVU generally did not correlate with 30 days postoperative complications in patients undergoing any surgery for brain tumor resection; however, the highest wRVU groups may be associated with greater risk of respiratory complications and need for transfusion. These finding suggests that wRVU may be a poor surrogate for case complexity 2).


In a cross-sectional review of registry data using the ACS NSQIP 2016 Participant User File and the Centers for Medicare & Medicaid Services physician procedure time file for 2018. Uppal et al. analyzed total RVUs for surgeries by operative time to calculate RVU per hour and stratified by specialty. Multivariate regression analysis adjusted for patient comorbidities, age, length of stay, and ACS NSQIP mortality and morbidity probabilities. The surgeon self-reported operative times from the Centers for Medicare & Medicaid Services physician were compared with operative times recorded in the ACS NSQIP, with excess time from RUC estimates termed “overreported time.”

Analysis of 901,917 surgeries revealed a wide variation in median RVU per hour between specialties. Orthopedics (14.3), neurosurgery (12.9), and general surgery (12.1) had the highest RVU per hour, whereas gynecology (10.2), plastic surgery (9.5), and otolaryngology (9) had the lowest (P<.001 for all comparisons). These results remained unchanged on multivariate regression analysis. General surgery had the highest median overreported operative time (+26 minutes) followed by neurosurgery (+23.5 minutes) and urology (+20 minutes). Overreporting of the operative time strongly correlated to higher RVU per hour (r=0.87, P=.002).

Despite reliable electronic records, the AMARUC continues to use inaccurate self-reported RUC surveys for operative times. This results in discrepancies in RVU per hour (and subsequent reimbursement) across specialties and a persistent disparity for women-specific procedures in gynecology. Relative value units levels should be based on the available objective data to eliminate these disparities 3).


1)

Satarasinghe P, Shah D, Koltz MT. The Perception and Impact of Relative Value Units (RVUs) and Quality-of-Care Compensation in Neurosurgery: A Literature Review. Healthcare (Basel). 2020 Dec 1;8(4):526. doi: 10.3390/healthcare8040526. PMID: 33271871; PMCID: PMC7711854.
2)

Kim RB, Scoville JP, Karsy M, Lim S, Jensen RL, Menacho ST. Work relative value units and perioperative outcomes in patients undergoing brain tumor surgery. Neurosurg Rev. 2021 Jul 8. doi: 10.1007/s10143-021-01601-6. Epub ahead of print. PMID: 34236568.
3)

Uppal S, Rice LW, Spencer RJ. Discrepancies Created by Surgeon Self-Reported Operative Time and the Effects on Procedural Relative Value Units and Reimbursement. Obstet Gynecol. 2021 Jul 8. doi: 10.1097/AOG.0000000000004467. Epub ahead of print. PMID: 34237766.

Operculoinsular cortectomy

Operculoinsular cortectomy

Operculoinsular cortectomy for refractory epilepsy is a relatively safe therapeutic option but temporary neurological deficits after surgery are frequent. A study of Bouthillier et al. highlighted the role of frontal/parietal opercula resections in postoperative complications. Corona radiata ischemic lesions are not clearly related to motor deficits. There were no obvious permanent neurological consequences of losing a part of an epileptic insula, including on the dominant side for language. A low complication rate can be achieved if the following conditions are met: 1) microsurgical technique is applied to spare cortical branches of the middle cerebral artery; 2) the resection of an opercula is done only if the opercula is part of the epileptic focus; and 3) the neurosurgeon involved has proper training and experience 1).


The goal of a study of Bouthillier et al. of the Sainte-Justine University Hospital CenterMontrealQuebecCanada, was to document seizure control outcome after operculoinsular cortectomy in a group of patients investigated and treated by an epilepsy team with 20 years of experience with this specific technique.

Clinical, imaging, surgical, and seizure control outcome data of all patients who underwent surgery for refractory epilepsy requiring an operculoinsular cortectomy were retrospectively reviewed. Tumors and progressive encephalitis cases were excluded. Descriptive and uni- and multivariate analyses were done to determine seizure control outcome and predictors.

Forty-three patients with 44 operculoinsular cortectomies were studied. Kaplan-Meier estimates of complete seizure freedom (first seizure recurrence excluding auras) for years 0.5, 1, 2, and 5 were 70.2%, 70.2%, 65.0%, and 65.0%, respectively. With patients with more than 1 year of follow-up, seizure control outcome Engel class I was achieved in 76.9% (mean follow-up duration 5.8 years; range 1.25-20 years). With multivariate analysis, unfavorable seizure outcome predictors were frontal lobe-like seizure semiology, shorter duration of epilepsy, and the use of intracranial electrodes for invasive monitoring. Suspected causes of recurrent seizures were sparing of the language cortex part of the focus, subtotal resection of cortical dysplasia/polymicrogyria, bilateral epilepsy, and residual epileptic cortex with normal preoperative MRI studies (insula, frontal lobe, posterior parieto-temporal, orbitofrontal).

The surgical treatment of operculoinsular refractory epilepsy is as effective as epilepsy surgery in other brain areas. These patients should be referred to centers with appropriate experience. A frontal lobe-like seizure semiology should command more sampling with invasive monitoring. Recordings with intracranial electrodes are not always required if the noninvasive investigation is conclusive. The complete resection of the epileptic zone is crucial to achieving good seizure control outcome 2).


In 2017 Bouthillier et al. published twenty-five patients underwent an epilepsy surgery requiring an operculoinsular cortectomy: mean age at surgery was 35 y (9-51), mean duration of epilepsy was 19 y (5-36), 14 were female, and mean duration of follow-up was 4.7 y (1-16). Magnetic resonance imaging of the operculoinsular area was normal or revealed questionable nonspecific findings in 72% of cases. Investigation with intracranial EEG electrodes was done in 17 patients. Surgery was performed on the dominant side for language in 7 patients. An opercular resection was performed in all but 2 patients who only had an insulectomy. Engel class I seizure control was achieved in 80% of patients. Postoperative neurological deficits (paresis, dysphasia, alteration of taste, smell, hearing, pain, and thermal perceptions) were frequent (75%) but always transient except for 1 patient with persistent mild alteration of thermal and pain perception. 3).

References

1)

Bouthillier A, Weil AG, Martineau L, Létourneau-Guillon L, Nguyen DK. Operculoinsular cortectomy for refractory epilepsy. Part 2: Is it safe? J Neurosurg. 2019 Sep 20:1-11. doi: 10.3171/2019.6.JNS191126. [Epub ahead of print] PubMed PMID: 31597116.
2)

Bouthillier A, Weil AG, Martineau L, Létourneau-Guillon L, Nguyen DK. Operculoinsular cortectomy for refractory epilepsy. Part 1: Is it effective? J Neurosurg. 2019 Sep 20:1-10. doi: 10.3171/2019.4.JNS1912. [Epub ahead of print] PubMed PMID: 31629321.
3)

Bouthillier A, Nguyen DK. Epilepsy Surgeries Requiring an Operculoinsular Cortectomy: Operative Technique and Results. Neurosurgery. 2017 Oct 1;81(4):602-612. doi: 10.1093/neuros/nyx080. PubMed PMID: 28419327.
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