key: cord-0843618-2syre8to
authors: Poorna, T. Anish; Joshna, E. K.; John, Bobby; Prakash, Prathibha
title: Palatal Flap: An Optimistic Salvagable Option to Negate the Maxillectomy Defects in COVID Related Rhino-Orbito-Cerebral Mucormycosis
date: 2022-01-09
journal: Indian J Otolaryngol Head Neck Surg
DOI: 10.1007/s12070-022-03084-3
sha: 55c3411f96945e332d7a979ca6d7d321c1235e6e
doc_id: 843618
cord_uid: 2syre8to

We present three cases diagnosed with COVID-19 associated Rhino-orbito-cerebral mucormycosis, managed by aggressive debridement and resection of the involved maxilla, followed by primary closure with preserved palatal flap, thus trying to establish its versatility for the closure of the maxillectomy defects.

It is a known fact that the tentacles of the pandemic corona virus have engulfed the humanity in all spheres of life. The Post-COVID period has become eventful by the unfortunate involvement of the various organ systems and its sequelae. The most debilitating one is the mucormycosis with its rhino orbital involvement [1] . Aggressive debridement or resection leave the scar of maxillectomy with its open sino-maxillary compartment making the individual embarrassed. In search of an ideal option for primary closure before definite reconstruction, we landed at the usage of palatal flap based on greater palatine and descending palatine arteries.

Arterial thrombosis, occlusion and vascular extension of the disease in mucormycosis may affect the versatile use of flaps for reconstruction [2] . Definite guide or protocol for reconstruction of maxillary defects in the management of mucormycosis does not exist in literature. However, reconstructive techniques commonly used for oncologic resection of maxilla can be applied to the defects after maxillectomy for mucormycosis [3] . Although some prefer delayed reconstruction after resection of the involved maxilla [3] , closure of the defect remains cumbersome as it is challenging in terms of restoring the form and function. Based on the algorithm for reconstruction of maxillectomy defects by Davison et al. the options extend from prosthesis, skin graft and local flaps to free vascularised flaps [4] . Reconstruction options include local flaps such as nasolabial flap, forehead flap, tongue flap, distant flaps such as temporalis and pectoralis flap and free flaps such as radial forearm, fibula and lattismus dorsi flaps [4] .

Preservation of the palatal soft tissue after debridement and debulking if hypertrophied, can act as a vital option in the primary closure of maxillectomy defects, provided the vascular supply is not violated and infrastructure maxillectomy is carried out. Careful dissection and preservation of the greater palatine vessels and descending palatine vessels are pivotal in maintaining the viability of the palatal flap [5] .

The advantages of preserving the palatal flap are, Here, we discuss three cases which portray the versatile use of the flap in Table 1 and Figs. 1, 2, 3 and 4 . All the patients who underwent closure with the palatal flap were reviewed every day post-operatively until discharge, and at the end of the first month. The antibiotic-soaked gauze packs were removed on the fifth post operative day, and the opening closed with 3-0 resorbable sutures under local anesthesia. Two patients had satisfactory healing whereas one patient had flap dehiscence on the fifth post operative day, which required re-suturing with 3-0 resorbable sutures under local anesthesia. Subsequent follow up at the end of the first month showed a good take-up of the flap and no further complications in any of the three patients. No oronasal regurgitation was present in any of the patients after the primary closure of the defect with the palatal flap, thus serving its functionality.

The preservation of soft tissue palatal flaps with careful handling of the vessels, thus maintaining viability, provides an excellent option at disposal for primary closure of the oro-nasal defects after unilateral or bilateral inferior maxillectomy, in the surgical management of COVID associated mucormycosis thus reducing the need for second incision and operative time drastically. Funding The authors did not receive any external source of funds or grants for the submitted work.

Conflict of interest The authors declare no conflict of interest.

Ethical Approval This is a case report study. The Institutional Review Board has confirmed that no ethical approval is required.

Informed Consent Written, informed consent has been obtained from the patients for their participation and publishing.

Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 

Mucormycosis in COVID-19: a systematic review of cases reported worldwide and in India

Carotid artery occlusion by rhinoorbitocerebral mucormycosis

Mucormycosis of the forehead and sinuses in a trauma patient

An algorithm for maxillectomy defect reconstruction

Palatal flap in bilateral inferior partial maxillectomy

Closure of oroantral fistula

COVID-19 associated mucormycosis: staging and management recommendations (report of a multi-disciplinary expert committee)