Paediatric nasal mucormycosis: Double whammy of a complex anatomical and physiologically difficult airway

Dear Editor, Paediatric nasal mucormycosis is a rare but severe infection with high morbidity and mortality, accounting for 7–16% of reported cases.1 It occurs in both immunocompromised and immunocompetent children. Around 20–30% of facial mucocutaneous mucormycosis cases occur in immunocompetent children.2 We report a rare case of an infant with mucormycosis complicated by a concurrent anatomical and physiologically difficult airway, a combination that is less described in the literature. A 52-day-old term male infant (5.1 kg), appropriate for gestational age, presented with fever and progressive respiratory distress, initially managed as bronchiolitis. Worsening hypoxaemia with acute respiratory distress syndrome (ARDS) necessitated mechanical ventilation for 72 hours, complicated by culture-proven Acinetobacter sepsis, septic shock, and multi-organ dysfunction syndrome. Adhesive fixation during ventilation caused necrosis of the left nasal ala and septum with black eschar Figure 1a. Histopathology revealed broad, aseptate, right-angle branching hyphae consistent with mucormycosis. Following treatment with culture-specific antibiotics (meropenem and tigecycline), liposomal amphotericin-B, and inotropes, the infant was stabilised, extubated, and then referred to our centre for urgent nasal debridement under general anaesthesia.Figure 1: (a) Infantile nasal mucormycosis with necrotic destruction of the left nasal ala. (b) Post-debridement intra-operative view of nasal mucormycosis illustrating anatomical airway challengeWritten informed consent was obtained from the parents, and the risks were briefed with a ventilator bed kept ready in the paediatric intensive care unit (PICU). The paediatric operating theatre was prepared with a difficult airway cart, including an age-appropriate supraglottic airway, a videolaryngoscope, a fibreoptic bronchoscope, and otorhinolaryngology backup for emergency front-of-neck access. The child was received in the operation theatre with an oxygen hood. Intravenous (IV) ketamine (1mg/kg) and IV glycopyrrolate (4 µg/kg) were administered, followed by pre-oxygenation, attempted with the larger-than-age-appropriate face mask placed upside down to create an effective seal without applying pressure to the necrotic tissue, using a gentle two-handed technique Figure 2a and b. Inhalational induction was carried out with a gradual increase in sevoflurane concentration while maintaining spontaneous ventilation. After confirming ventilation, IV propofol (10 mg), fentanyl (6 µg), and atracurium (2.5 mg) were administered. Direct laryngoscopy was done, and the trachea was intubated with a 3.5-mm oral micro-cuffed endotracheal tube. Inotropic support and normothermia were maintained intra-operatively, and the infant was transferred to the PICU after debridement Figure 1b for post-operative ventilation. The child was extubated after 24 h and was planned for a forehead graft.Figure 2: Representative image showing a larger-than-age-appropriate facemask held upside down, as done in the index case. (a) Front view. (b) Lateral viewMucormycosis is a rapidly progressive, angio-invasive fungal infection caused by Mucorales, mainly Rhizopus and Mucor, with a high mortality rate.3 Paediatric cases predominantly affect immunocompromised children and are associated with sepsis, extended intensive care unit stays, ventilation, and steroid use.3 The most common risk factor is haematological malignancy (46%), followed by haematopoietic stem cell transplantation (16%) and solid organ transplantation (4.8%). Less frequent factors include diabetes mellitus (5%), trauma (5%), and no underlying illness (9.5%).4 In our index case, nasal trauma related to adhesive tape and immunocompromised status likely facilitated fungal inoculation, resulting in septal involvement and creating significant airway challenges during anaesthesia. A facial boil in an immunocompetent 6-month-old child led to a fulminant mucocutaneous mucormycosis infection in the case described by ALGhabra et al.2 The underlying mechanism, involving sub-clinical breaches in the skin barrier and small abrasions similar to those in our case, can weaken skin integrity and act as a pathway for fungal inoculation. This case demonstrates a complex airway involving both an anatomical and a physiologically difficult airway. Disruption of the nasal ala and vestibule, coupled with facial asymmetry due to oedema, friable necrotic tissue, and a risk of bleeding, can lead to failure of conventional mask ventilation.5 Additionally, low functional residual capacity, high oxygen consumption, and limited reserves in infants—exacerbated by ARDS, sepsis, and multi-organ dysfunction syndrome—predispose to rapid hypoxaemia during airway manipulation. Effective mask ventilation is vital in paediatric airway management as most catastrophic events in infants result from failure to ventilate rather than intubate.6 Nasal mucormycosis, with its extension, distorts facial anatomy, and the surrounding friable, easy-to-bleed tissue makes mask ventilation a challenge. In our case, an inverted, larger-than-age-appropriate face mask improved the seal by redistributing pressure away from friable necrotic tissue, reducing bleeding and preventing further tissue injury. Spontaneous ventilation was maintained during induction due to anticipated airway difficulty and limited physiological reserve as its loss could cause catastrophic hypoxaemia. Inhalational induction with gentle two-handed mask ventilation allowed continuous assessment while avoiding nasal adjuncts and repeated instrumentation, thereby minimising tissue disruption, bleeding, fungal spread, airway trauma, and post-operative respiratory compromise. This highlights the value of simple, reproducible airway strategies in resource-limited settings. To conclude, paediatric nasal mucormycosis is a rare entity with significant airway difficulties caused by both anatomical and physiological factors. This highlights the importance of early detection and practical airway management techniques, such as using an inverted face mask, which is a simple and effective solution for midfacial necrosis. Disclosure of use of artificial intelligence (AI)-assistive or generative tools The AI tools or language models (LLM) have not been utilised in the manuscript preparation. Declaration of patient consent Written informed consent was obtained from the patient’s parents for publication of clinical information and images, with due efforts to ensure anonymity, although complete confidentiality cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.