Endoscopic Sphenoid Sinus Surgery for the Sequestrated Lateral Recess in the Management of Mucormycosis

Objective: We report a rare case of mucormycosis of the sphenoid sinus, where the well-developed lateral recess constituted a separate compartment, necessitating a second surgery after an initial endoscopic attempt of curettage in the main sinus cavity.

Clinical Presentation: A 61-year-old woman presented with symptoms of severe headache, double vision, and ptosis of the left eye. Her initial CT scans and MR images showed a huge, expansile mass in the sphenoid sinus destroying the clivus, but results were not conclusive for the diagnosis.

Intervention: She underwent endoscopic endonasal surgery for exploration into the sphenoid sinus. The sinus was filled with creamy caseous necrotic materials. Curettage of contents was done. Histopathological examination led to diagnosis of mycetoma of the mucor. Although the main sinus became clear postoperatively, the right lateral recess turned out a separate cavity, still containing infected materials. We therefore conducted the second surgery 2 weeks later. The lateral recess was accessed via the main sinus cavity by removing a septum, and thoroughly irrigated with the mucosa remaining intact. Following surgery, we administered liposomal amphotericin B (3mg/kg/day) intravenously for 4 weeks.

Conclusion: In mucormycosis involving the sphenoid sinus, diagnostic evaluation for possible sequestration of the lateral recess should be considered. Treatment of these lesions includes extensive surgical curettage, irrigation, and subsequent intravenous high-dose amphotericin B. Modes of surgery should be based on several factors including risk factors, condition of the host, and extent of the fungal invasion. Purely endoscopic approaches may be sufficient in selected cases.