CLINICAL STUDY

Neuronavigation-Guided Endoscopic Endonasal
Resection of Extensive Skull Base Mucormycosis
Complicated With Cerebral Vasospasm
Bashar Abuzayed, MD,* Hussein Al-Abadi, MD,† Shade Al-Otti, MD,‡
Khaled Baniyaseen, MD,§ and Yasameen Al-Sharki, MD§
Abstract: A 24-year-old woman presented with double vision since
6 months. Examination revealed left eye ptosis and bilateral abducens
nerve palsy. Brain computed tomographic scan and magnetic resonance imaging revealed a bone-eroding mass lesion located in the
middle skull base, occupying the posterior ethmoidal cells, the planum
sphenoidale, the sphenoid sinus, the lateral recesses of the sphenois sinus, the pterygoid apexes, and the middle and lower clivus, with compression of the inferior wall of the cavernous sinus and the parasellar
and paraclival parts of the internal carotid artery. The patient was operated on with extended endoscopic endonasal approach guided with
neuronavigation. Total mass resection was achieved. Histopathologic
examination revealed mucormycosis infectious mass. On postoperative day 5, the patient developed right hemiplegia, and brain imaging
revealed left internal carotid vasospasm. After treatment, the patient
improved and was discharged.
Key Words: Extended endoscopic endonasal approach,
mucormycosis, neuronavigation, skull base, vasospasm
(J Craniofac Surg 2014;25: 1319–1323)

M

ucormycosis is an invasive fungal infection with predilection for
the paranasal sinuses.1 Despite the advances in diagnosis and
treatment, invasive rhino-orbito-cerebral infection is still the most lethal clinical form of the disease.2–4 The mortality rate is reported to
be as high as 20% even if the diagnosis and aggressive treatment are
not delayed.5
Despite these efforts, these approaches are still considered invasive, requiring various degrees of bone demolition and neurovascular
manipulation. With the introduction of the functional endoscopic sinus
surgery, endoscopic techniques and approaches were developed starting
from diagnosing techniques6,7 to endoscopic endonasal transsphenoidal
pituitary8 and extended endoscopic skull base surgeries.9–14 The endoscopic endonasal approach to the midline skull base has become a popular approach for the surgical management of pathologic lesions occupying
this region. This popularity was gained because of the advantages offered
by this technique, such as minimal invasiveness, less neurovascular
From the *Department of Neurosurgery, Al Bashir Government Hospital, Amman,
Jordan; and Departments of †Neurosurgery, ‡Surgery, and §Pathology, Prince
Hamza Hospital, Amman, Jordan.
Received December 3, 2013.
Accepted for publication January 17, 2014.
Address correspondence and reprint requests to Bashar Abuzayed, MD,
Department of Neurosurgery, Al Bashir Government Hospital, PO Box
10005, Amman, Jordan; E-mail: sylvius@live.com
The authors report no conflicts of interest.
Copyright © 2014 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000000786

retraction and thus lower risk for neurovascular injury, wide view of exposure, no disruption of the facial skeleton, and better postoperative performance of the patients with shorter hospitalization period.
In this report, we present a case of invasive skull base mucormycosis that was treated successfully with complete removal of the
mass with neuronavigation-guided extended endoscopic endonasal
skull base approach, and complicated with postoperative internal carotid artery (ICA) vasospasm, representing an interesting triad of rare
disease, novel surgical technique, and unusual complication.

CLINICAL REPORT
A 24-year-old woman presented with double vision since
6 months. The patient had no significant medical history. On admission, the neurologic examination revealed left eye ptosis and bilateral
abducens nerve palsy with total inability to move both eyes laterally.
Brain computed tomographic (CT) scan revealed a mass lesion located in the middle skull base, occupying the posterior ethmoidal
cells, the planum sphenoidale, the sphenoid sinus, the lateral recesses
of the sphenois sinus, the pterygoid apexes, and the middle and lower
clivus. The mass was seen eroding the bones of the skull base and
showing homogenic hyperdense signal with areas of air. Brain magnetic resonance imaging (MRI) showed a cystic mass lesion in the upper mentioned areas. The mass was extending to and compressing the
inferior wall of the cavernous sinus and the parasellar and paraclival
parts of the ICA. The mass was hyperintense on T1-weighted and
hypointense on T2-weighted images, with homogenous enhancement
with gadolinium on postcontrast images. The mass showed strong
capsule enhancement around the mass. Brain magnetic resonance angiography (MRA) showed no abnormalities in the intracranial arteries
(Fig. 1). On the basis of the radiologic appearance and location of
the tumor, we applied extended endoscopic endonasal approach to remove the tumor guided with neuronavigation.

Operative Technique
The patient was placed in supine position, with the head in neutral position and with a 10- to 15-degree adduction toward the left shoulder to prevent the surgeon’s lateral bending and to avoid fatigue.
The operation was performed using Karl Storz 0- and 30-degree,
4-mm–diameter, 18-cm, and 30-cm rod-lens rigid telescopes (Karl
Storz and Co, Tuttlingen, Germany). The endoscopic approach was
aided by neuronavigation (Stealth Station Treon plus; Medtronic,
Louisville, CO) (Fig. 2). The endoscope was introduced binostrally,
biolateral middle turbinate resection was performed, and the sphenoid ostium was identified. The posterior portion of the nasal septum and the vomer were resected to expose the whole anterior wall of the sphenoid sinus
and the clivus. In addition, the superior portion of the nasal septum was
resected to expose the skull base (the floor of the posterior ethmoid cells).
After preparing the surgical corridor in the nasal step, the ostia of
the sphenoid sinus were identified in the sphenoethmoidal recess. After
large anterior sphenoidectomy, the optic protuberance was identified in

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Abuzayed et al

The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014

far lateral) approach. After exposure of the bone of the inferior part
of the cavernous sinus and the middle cranial fossa, bone resection
is continued laterally from the lateral border of the parasellar ICA until
the level of the pterygoid apex. The vidian nerve (the sphenopalatine
nerve) exits from the vidian canal, which is located in the pterygoid
base, inferior to the ICA segment between the vertical paraclival segment and the horizontal petrous segment (lacerum segment). Thus, the
vidian nerve is a good landmark locating the lacerum segment of the
ICA at the turning point between the paraclival and petrous portions.
During bone resection to expose the sella, the clivus, the anterior skull base, and the pterygoid apex, the bone was found lytic and
fragile. Underneath, a mass of soft grayish tissue with cystic areas
filled with serous fluid was seen. During mass resection, the dura of
the anterior skull base (planum ethmoidale), the planum sphenoidale,
the sella, the inferior part of both cavernous sinuses, and the middle
and lower clivus were exposed (Fig. 3). During the resection, an arterial bleeding was seen medial to the left parasellar carotid artery, at
the level of the posterior carotid bend and lateral to the sella. This
bleeding was controlled by coagulation. The extent of the resection
was from the lower clivus inferiorly to the anterior ethmoidal cells superiorly and the both lateral recesses of the sphenoid sinus, the pterygoid apexes, and the paraclival carotid arteries laterally.
FIGURE 1. Preoperative neuroimages demonstrating the skull base mass.
A, Brain CT scan; B, brain MRA; C, sagittal T2-weighted brain MRI; D, axial
postcontrast enhancing brain MRI.

the sphenoid roof. Using the anatomic landmarks in the sphenoid sinus roof and with the control of neuronavigation, the posterior ethmoidal cells located anterosuperior to the sphenoid sinus were
resected until the lamina papyracea was exposed laterally; the roof
of the posterior ethmoidal cells, superiorly; and the middle turbinate
basal lamella, anteriorly (posterior to anterior approach).
With opening of the lateral recesses of the sphenoid sinus combined
with the resection of the posterior ethmoidal cells, the pterygoid apex was
exposed bilaterally, which is called the ethmoidopterygosphenoidal (or

FIGURE 2. Application of intraoperative neuronavigation. Planning of
the approach is demonstrated through the endonasal route toward the skull
base mass.

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Postoperative Course
The patient was extubated, and immediate neurologic examination revealed new deficits. The first postoperative day brain MRI
showed total resection of the mass (Fig. 4). Histopathologic examination revealed loose fibrovascular tissue lined by benign respiratory epithelium and containing aggregates of multinucleated giant
cells engulfing fungal branching hyphae positive for periodic
acid–Schiff (PAS) and surrounded by rich eosinophils infiltration.
The same fungi were arranged in the perivascular array and diagnosed as mucormycosis (Fig. 5). Accordingly, 0.7 mg/kg per day
of intravenously injected amphotericin B was started. In the third
postoperative day, the bilateral abducens nerve palsy started to regress and the patient started to move the eyes to both sides. In the
fifth postoperative day, the patient complained of right-sided weakness, and examination revealed hemiparesis with motor power of
3 of 5, which became total hemiplegia in the sixth postoperative
day. Brain MRI showed ischemia in the left anterior internal capsule,
the head of caudate nucleus, the anterior perforating area, and frontal
subcortical areas. Brain MRA showed severe vasospasm in the left internal carotid (Fig. 6). Triple H (hypertension, hypervolemia, and
hemodilation) therapy and 0.6 mL of low–molecular-weight heparin
1 dose daily were started. This therapy was continued for 10 days
in which the patient showed motor improvement. The patient was

FIGURE 3. A, Intraoperative view showing the dura and related underlying
structures after mass resection. B, An endoscopic endonasal cadaver dissection
to the same area compared with the endoscopic view in A. C indicates clivus;
CS-I, inferior wall of cavernous sinus; ICA-a, anterior bend of ICA; ICA-C,
paraclival part of ICA; ICA-p, posterior bend of ICA; ON, optic nerve; PG,
pituitary gland. Adapted from Abuzayed et al.11

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014

Endonasal Resection of Mucormycosis

FIGURE 6. Neuroimages at postoperative day 6 after development of the right
hemiplegia, demonstrating left ICA vasospasm in the brain MRA (arrow) (A),
and the ischemic areas in the left anterior internal capsule, the head of caudate
nucleus, the anterior perforating area, and frontal subcortical areas in axial
T2-weighted brain MRI (B, C).
FIGURE 4. Postoperative neuroimages demonstrating the total resection of
the skull base mass. A, Brain CT scan; B, axial postcontrast enhancing brain MRI;
C, sagittal T2-weighted brain MRI.

discharged with final motor power of 4 of 5, resolved abducens nerve
palsy, and improved left eye ptosis.

DISCUSSION
Mucormycosis is an invasive fungal infection first described by
Paulltauf in 1885.15 The causative agents of mucormycosis are the filamentous fungi of the Mucoraceae family of the order Mucorales,
subphylum Mucormycotina, which are also found in normal human
nasal flora.16 The most frequently isolated species is Rhizopus oryzae
followed by Rhizopus microsporus and Absidia corymbifera.17 Infections by members of the order Mucorales are primarily opportunistic infections and represent the third leading cause of invasive
fungal infections after Aspergillus and Candida species.18 The disease may present with various manifestations, but there is a predilection
for the paranasal sinuses.18 Rhinocerebral mucormycosis is also referred
to as rhino-orbito-cerebral mucormycosis in the respective literature to
denote involvement of the orbital structures. Extension of the disease
to the orbit and the brain is a grave concern and is often seen in

FIGURE 5. A, A photomicrograph showing PAS-positive fungal branching
hyphae and surrounded by rich eosinophils infiltration. B, A photomicrograph
showing the PAS-positive fungal hyphae arranged around and invading the
perivascular area (arrow).

patients with immunosuppression.19 However, in our case, the patient
had no significant medical history or history of possible exposure. All
tests of our patient showed immunocompromised status.
The locoregional spread pathway of rhinocerebral mucormycosis
has not been adequately described. Hosseini and Borghei20 regarded
the pterygopalatine fossa as a reservoir of the disease through which
it can spread to neighboring structures including the retroglobal space
of the orbit and the infratemporal fossa. On the contrary, angioinvasion
by the fungi has been studied to a greater extent and is considered central to its ability to cause tissue necrosis and dissemination.21,22 In addition, invasive mucormycosis of the paranasal sinuses has an affinity
for blood vessel walls and may cause cavernous sinus and ICA thrombosis, which were not evident in either of our cases; surrounding soft
tissue infarction may also occur.22
The common presenting symptoms and signs are headache, fever, acute sinusitis, decreased vision, unilateral periorbital or facial
swelling, facial pain, alterations in mental state, and necrotic ulcer in
the nasal or the oral mucosa.23 Although rare, orbital apex syndrome,
which presents with ptosis, proptosis, sensorial deficit, and visual
loss, may be the initial manifestation of the disease.24 In our case,
our patient’s first presentation was left eye ptosis and bilateral
abducens nerve palsy, correlating with invasiveness of the disease.
Histopathologic examination of surgical specimens can confirm the clinical diagnosis with the appearance of right-branching
aseptate hyphae, which are considered typical of Mucor species,
along with evidence of angioinvasion and tissue necrosis.25 Fungal
cultures can provide further confirmation. However, a large number
of false-negative results have been reported compared with direct
histopathologic examination.26 Speciation and susceptibility tests
can also be ordered, although this information is more of scientific
and epidemiologic interest with no clinical implications because the
treatment plan is uniform in all cases.27 Other laboratory diagnostic
modalities include molecular detection of Zygomycetes, which has
been available, but the results so far have been less than promising.28
Cerebrospinal fluid analysis has also been reported as helpful in the
diagnosis in few reports.29 However, isolation of the fungi from blood
cultures and cerebrospinal fluid should not be considered normal.21
Surgical intervention has been associated in large series with
favorable outcome.30,31 However, no formal guidelines have been

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Abuzayed et al

The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014

formulated as to the timing and extent of appropriate surgical management.32 Reed et al33 advocate an “aggressive-conservative” approach with frozen section–guided surgical exploration, sparing
uninvolved orbital structures, whereas Nithyanandam et al30 support a more aggressive approach with early excision of infected
structures. Although orbital exenteration has been reported as helpful
even in the context of intracranial spread, the topic of orbital exenteration has not been adequately studied, thereby necessitating individualization of surgical intervention.27,33 Irrigation of the surgical site
with amphotericin B solution has also been proposed based on the
vaso-occlusive nature of the infection, which leads to reduced delivery of antibiotics to infected areas.34
The midline skull base is an anatomic area that covers the
upper nasal and oral cavities, and it extends from the crista galli to
the lower clivus.35 This region is a site for a variety of pathologies,
which are considered surgically challenging because of its critical location and neighboring neurovascular structures. Many transfacial
and transcranial approaches were proposed,36–39 which are considered
aggressive because of large incisions and flaps; facial skeleton disturbance; cosmetic problems; wide neurovascular manipulation and retraction; and patients’ difficulty in tolerating the surgery because of
bad general condition, especially for those with oncologic pathologies. Surgeons started to seek more minimally invasive techniques
to avoid these difficulties. Endoscopic visualization from “below”
has offered the surgeons the possibility to reach the midline anterior
skull base without skin incision and brain retraction and with minimal neurovascular manipulation.9–14
As neurosurgeons, we found the posterior-anterior approach
to be more suitable in performing ethmoidectomy and exposing the
anterior skull base. The reason is that early identification of the sphenoid sinus and the sellar and parasellar regions, which are well known
to neurosurgeons, can be achieved using this approach.9 Thus, early
opening of the anterior wall of the sphenoid sinus and exposure of
the sphenoid sinus roof with its anatomic landmarks, which the neurosurgeon is more familiar with, can help us to conserve orientation of
the dissection direction toward the ethmoid sinus, with more controlled orientation to the critical neighboring neurovascular structures,
with less risk for their injury. On the other hand, the anterior-posterior
approach needs specific knowledge of the anatomy of the ethmoidal
cells and in-depth experience in endoscopic sinus surgery, with
good orientation while “moving” inside the ethmoidal cells, which
the otorhinolaryngologists are most familiar with. The anterior skull
base is exposed from the 2 medial orbital walls and optic nerves bilaterally, the sella posteriorly, and the frontal recesses anteriorly, which
can provide us with good and wide access to many pathologies of
this region. Early identification of anterior and posterior ethmoidal
arteries is very important to avoid the risk for their injury and early
devascularization of some tumors in this region.9,12,13
The sellar floor is resected laterally toward the carotid protuberance to expose the parasellar portion of the ICA. This resection is
continued laterally until the lateral border of the ICA, thus exposing
the inferior part of the cavernous sinus. Both the anterior and posterior bends of the parasellar portion of the ICA are widely exposed.8,10
To expose the inferior portion of the cavernous sinus, the superior and
middle turbinates and the posterior ethmoidal cells are removed
(extended endoscopic endonasal transsphenoidal approach). The anatomic landmarks in the roof of the sphenoid sinus are valuable to determine the anatomic location of the cavernous sinus. The ICA, with
its parasellar and paraclival parts, is delineated by the carotid protuberance, with the sellar fossa located medially. In addition, when the lateral septae of the sphenoid sinus exist, these are generally attached to
the carotid protuberance and point to the location of the ICA.10 These
important landmarks can help locate the intercavernous ICA and the
cavernous sinus before bone resection and opening of the dura, which

1322

offers a safer approach.10 Including the sellar fossa in the bone resection is preferred because wide exposure of the related structures
avoids blind manipulation and creates a space for ICA retraction when
needed. After exposure of the bone of the inferior part of the cavernous sinus and the middle cranial fossa, bone resection is continued laterally from the lateral border of the parasellar ICA until the level of the
pterygoid apex. The vidian nerve (the sphenopalatine nerve) exits
from the vidian canal, which is located in the pterygoid base, inferior
to the ICA segment between the vertical paraclival segment and the
horizontal petrous segment (lacerum segment).10,40 Thus, the vidian
nerve is a good landmark locating the lacerum segment of the ICA
at the turning point between the paraclival and petrous portions.10,40
When the opening of the vidian canal is required to expose the vidian
nerve and/or approaching pathologies in the pterygopalatine fossa,
drilling of the canal is recommended to be started from the inferior
and the medial aspect of the canal because the ICA is located along
the superior margin.10,40 This will decrease the risk for intraoperative injury of the ICA during drilling of the vidian canal. After
identifying the vidian nerve, a triangular area lateral to the ICA can be
identified. The base of this triangle is formed by the vidian nerve inferiorly with the apex pointing superiorly. The lateral arm of the triangle is formed by the medial pterygoid process, and the medial arm is
formed by the parasellar ICA.
The endoscopic endonasal route offers a direct access to the
clivus, compared with microscopic anterior approaches, with the lateral limit of the surgical corridor being the vidian nerve superiorly
and the paraclival portion of the ICA inferiorly.11 Thus, surgically
challenging intradural and/or extradural lesions located anteriorly to
the brain stem and the foramen magnum can be treated with this approach. In addition, because of the lateral exposure offered by angled
lenses, this approach can offer resection of the lateral parts of the
tumors without the need for lateral facial osteotomies. Another advantage of this approach is the lack of the need for soft palate splitting in
contrast to transoral approaches, thus avoiding postoperative wound
healing problems and facilitating early oral intake.
Inadvertent ICA injury occurs in 3% to 5% of skull base
procedures, with an additional 1.9% of patients having carotid artery
vasospasm.41 The timing of vasospasm after tumor resection is similar
to that observed after aneurysmal subarachnoid hemorrhage and is optimally managed using similar interventions, including hyperdynamic
therapy and/or endovascular injection of vasodilating agents. In our
case, vasospasm developed in postoperative day 5. Although there
was a possibility of vasculitis as a known complication of invasive
mucormycosis,23 the timing of the vascular occlusion and the good response to the vasospasm standard triple H therapy (hypertension,
hypervolemia, and hemodilation) favored the diagnosis of vasospasm.
A possible explanation of this complication is that it resulted because
of the coagulation and thermal injury to the walls of the ICA or irritation of the ICA nerve plexus because it corresponds well to the side
and the site of coagulation in the left parasellar carotid artery, at the
level of the posterior carotid bend and lateral to the sella.
Medical treatment of cerebrorhinal mucormycosis includes
amphotericin B deoxycholate, which remains the only licensed antifungal agent for mucormycosis. However, lipid formulations of
amphotericin B are considered a safe and efficient alternative.32 Liposomal amphotericin B in particular has been proven superior to
amphotericin B deoxycholate, whereas amphotericin B lipid complex
has been reported to be effective as part of a combination treatment
with caspofungin.33 Recommended starting doses for the lipid formulation of amphotericin are 5 to 7.5 mg/kg per day, with higher dosages
(up to 10 mg/kg per day) recommended for central nervous system involvement.32 Iron chelation therapy and posaconazole should be considered in cases of refractory infection or polyene intolerance.32
Regarding the duration of treatment, Spellberg et al32 specify the
© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014

resolution of immunosuppression, radiographic signs, and clinical
symptoms as the objectives of treatment. Deferasirox and deferiprone
are new iron chelators, which, in contrast to deferoxamine, cannot be
used by the fungi as siderophores.23
Despite the advances in diagnosis and treatment, invasive
rhino-orbito-cerebral infection is still the most lethal clinical form of
the disease.2–4 The mortality rate is reported to be as high as 20% even
if the diagnosis and aggressive treatment are not delayed.5 Besides
prompt diagnosis and aggressive treatment, the extent of the infection
and the prognosis of the underlying disease affect the survival, and
this may explain why the mortality rates have been indicated up to
40% to 50% in the literature.4,5

REFERENCES
1. Yousem DM, Galetta SL, Gusnard DA, et al. MR findings in
rhinocerebral mucormycosis. J Comput Assist Tomogr 1989;13:878–882
2. Hussain S, Salahuddin N, Ahmad I, et al. Rhinocerebral invasive
mycosis: occurrence in immunocompetent individuals. Eur J Radiol
1995;20:151–155
3. Silverman CS, Mancuso AA. Periantral soft-tissue infiltration and
its relevance to the early detection of invasive fungal sinusitis: CT
and MR findings. AJNR Am J Neuroradiol 1998;19:321–325
4. Fairley C, Sullivan TJ, Bartley P, et al. Survival after
rhino-orbital-cerebral mucormycosis in an immunocompetent patient.
Ophthalmology 2000;107:555–558
5. Warwar RE, Bullock JD. Rhino-orbital-cerebral mucormycosis:
a review. Orbit 1998;17:237–245
6. Messerklinger W. Role of the lateral nasal wall in the pathogenesis,
diagnosis and therapy of recurrent and chronic rhinosinusitis
[in German]. Laryngol Rhinol Otol (Stuttg) 1987;66:293–299
7. Stammberger H, Posawetz W. Functional endoscopic sinus surgery.
Concept, indications and results of the Messerklinger technique.
Eur Arch Otorhinolaryngol 1990;247:63–76
8. Abuzayed B, Tanriöver N, Ozlen F, et al. Endoscopic endonasal
transsphenoidal approach to the sellar region: results of endoscopic
dissection on 30 cadavers. Turk Neurosurg 2009;19:237–244
9. Abuzayed B, Tanriover N, Gazioglu N, et al. Endoscopic endonasal
anatomy and approaches to the anterior skull base: a neurosurgeon’s
viewpoint. J Craniofac Surg 2010;21:529–537
10. Abuzayed B, Tanriover N, Gazioglu N, et al. Endoscopic anatomy and
approaches of the cavernous sinus: cadaver study. Surg Radiol Anat
2010;32:499–508
11. Abuzayed B, Tanriover N, Gazioglu N, et al. Extended endoscopic
endonasal approach to the clival region. J Craniofac Surg
2010;21:245–251
12. Abuzayed B, Tanriover N, Gazioglu N, et al. Endoscopic endonasal
approach to the orbital apex and medial orbital wall: anatomic study and
clinical applications. J Craniofac Surg 2009;20:1594–1600
13. Gazioglu N, Abuzayed B, Tanriover N. Neuronavigation-guided
endoscopic endonasal excision of an intraorbital intraconal cavernous
hemangioma. J Craniofac Surg 2011;22:1802–1805
14. Abuzayed B, Tanriover N, Gazioglu N, et al. Extended endoscopic
endonasal approach to the pterygopalatine fossa: anatomic study.
J Neurosurg Sci 2009;53:37–44
15. Mallis A, Mastronikolis SN, Naxakis SS, et al. Rhinocerebral
mucormycosis: an update. Eur Rev Med Pharmacol Sci
2010;14:987–992
16. Hibbett DS, Binder M, Bischoff JF, et al. A higher-level phylogenetic
classification of the fungi. Mycol Res 2007;111:509–547
17. Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human disease.
Clin Microbiol Rev 2000;13:236–301
18. Pagano L, Offidani M, Fianchi L, et al. Mucormycosis in hematologic
patients. Haematologica 2004;89:207–214

Endonasal Resection of Mucormycosis

19. Nussbaum ES, Hall WA. Rhinocerebral mucormycosis: changing
patterns of disease. Surg Neurol 1994;41:152–156
20. Hosseini SM, Borghei P. Rhinocerebral mucormycosis: pathways of
spread. Eur Arch Otorhinolaryngol 2005;262:932–938
21. Spellberg B, Edwards J Jr, Ibrahim A. Novel perspectives on
mucormycosis: pathophysiology, presentation, and management. Clin
Microbiol Rev 2005;18:556–569
22. Ibrahim AS, Spellberg B, Avanessian V, et al. Rhizopus oryzae adheres
to, is phagocytosed by, and damages endothelial cells in vitro. Infect
Immun 2005;73:778–783
23. Haliloglu NU, Yesilirmak Z, Erden A, et al. Rhino-orbito-cerebral
mucormycosis: report of two cases and review of the literature.
Dentomaxillofac Radiol 2008;37:161–166
24. Karakurum B, Karatas M, Cagici AC, et al. Mucormycosis presenting
with painful ophthalmoplegia. Acta Neurol Belg 2005;105:201–205
25. Lass-Flörl C. Zygomycosis: conventional laboratory diagnosis. Clin
Microbiol Infect 2009;15:60–65
26. Greenberg RN, Scott LJ, Vaughn HH, et al. Zygomycosis
(mucormycosis): emerging clinical importance and new treatments.
Curr Opin Infect Dis 2004;17:517–525
27. O’Neill BM, Alessi AS, George EB, et al. Disseminated rhinocerebral
mucormycosis: a case report and review of the literature. J Oral
Maxillofac Surg 2006;64:326–333
28. Hall L, Wohlfiel S, Roberts GD. Experience with the MicroSeq D2
large-subunit ribosomal DNA sequencing kit for identification of
filamentous fungi encountered in the clinical laboratory. J Clin
Microbiol 2004;42:622–626
29. Bengel D, Susa M, Schreiber H, et al. Early diagnosis of rhinocerebral
mucormycosis by cerebrospinal fluid analysis and determination of
16s rRNA gene sequence. Eur J Neurol 2007; 14:1067–1070
30. Nithyanandam S, Jacob MS, Battu RR, et al. Rhino-orbito-cerebral
mucormycosis. A retrospective analysis of clinical features and
treatment outcomes. Indian J Ophthalmol 2003;51:231–236
31. Peterson KL, Wang M, Canalis RF, et al. Rhinocerebral mucormycosis:
evolution of the disease and treatment options. Laryngoscope
1997;107:855–862
32. Spellberg B, Walsh TJ, Kontoyiannis DP, et al. Recent advances in the
management of mucormycosis: from bench to bedside. Clin Infect Dis
2009;48:1743–1751
33. Reed C, Bryant R, Ibrahim AS, et al. Combination polyene-caspofungin
treatment of rhino-orbital-cerebral mucormycosis. Clin Infect Dis
2008;47:364–371
34. Yohai RA, Bullock JD, Aziz AA, et al. Survival factors in
rhino-orbital-cerebral mucormycosis. Surv Ophthalmol 1994;39:3–22
35. Cavallo LM, Messina A, Cappabianca P, et al. Endoscopic endonasal
surgery of the midline skull base: anatomical study and clinical
considerations. Neurosurg Focus 2005;19:E2
36. Al-Mefty O. Supraorbital-pterional approach to skull base lesions.
Neurosurgery 1987;21:474–477
37. Blacklock JB, Weber RS, Lee YY, et al. Transcranial resection of
tumors of the paranasal sinuses and nasal cavity. J Neurosurg
1989;71:10–15
38. Cheesman AD, Lund VJ, Howard DJ. Craniofacial resection for
tumors of the nasal cavity and paranasal sinuses. Head Neck Surg
1986;8:429–435
39. McCutcheon IE, Blacklock JB, Weber RS, et al. Anterior transcranial
(craniofacial) resection of tumors of the paranasal sinuses: surgical
technique and results. Neurosurgery 1996;38:471–479
40. Kassam AB, Prevedello DM, Carrau RL, et al. The front door to
Meckel’s cave: an anteromedial corridor via expanded endoscopic
endonasal approach—technical considerations and clinical series.
Neurosurgery 2009;64(suppl 3):71–82
41. Hearst MJ, Kadar A, Keller JT, et al. Petrous carotid canal
dehiscence: an anatomic and radiographic study. Otol Neurotol
2008;29:1001–1004

© 2014 Mutaz B. Habal, MD

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