Introduction
During the second wave of the coronavirus disease 2019 (Covid-19) pandemic, due to systemic immune alterations caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and the possible overzealous use of steroids, there was an exponential rise in post-coronavirus rhino-orbital mucormycosis cases over eight weeks from the period of May 2021 to June 2021 that overwhelmed the surgical teams dealing with their management. These patients were treated with amphotericin B along with aggressive surgical debridement. Maxillectomy was indicated in cases with osteomyelitis of the maxilla, resulting in extensive maxillary defects.
In the pre-coronavirus era, in patients scheduled to undergo maxillectomy for rhino-orbital mucormycois cases, a primary impression of the hard palate was made by prosthodontists pre-operatively, and surgical obturators made of acrylic were created before the surgery and inserted intra-operatively. Surgical obturators helped restore functional losses early in the post-operative period in patients who underwent maxillectomy.
Given the overwhelming number of mucormycosis cases during the second wave of the Covid-19 pandemic, especially those with concurrent coronavirus and mucormycosis, it was not easy to rehabilitate patients with obturators soon after the surgery. This predicament was dealt with using an innovative, cost-effective and convenient method employing commercially available high-density polyurethane foam that served the function of an obturator during the hospital stay.
The present report concerns an innovative obturator made of polyurethane foam used to rehabilitate maxillectomy patients in a tertiary care centre that treated 153 cases of post-coronavirus rhino-orbital mucormycosis.
Materials and methods
The novel method of using high-density polyurethane foam was employed in a tertiary care centre that had 153 cases of post-coronavirus rhino-orbital mucormycosis in eight weeks, from May 2021 to June 2021. Treatment modalities for rhino-orbital mucormycosis included amphotericin B and surgical debridement. In patients who underwent maxillectomy, the post-operative cavity was packed with medicated ribbon gauze, which was removed 2 days after surgery.
Before the pandemic, in all cases planned for maxillectomy, a dental impression of patients' hard palate was made by a prosthodontist, which would be used to make a surgical obturator to be wired into position following maxillectomy. However, the explosive increase in post-coronavirus mucormycosis, the need for emergency surgery round the clock, and the restrictions brought about by the second wave of the coronavirus pandemic disrupted dental practices around the country and made the availability of surgical obturators scarce.
When searching for a novel, readily available and cost-effective obturator, the utility of high-density polyurethane foam to make an obturator was discussed. A temporary obturator was used during patients’ oral feeds in the first few days following maxillectomy, and nasogastric tubes were avoided. Undyed high-density polyurethane foam, traditionally used in the furniture industry to make cushions and seats, was procured in large cubes, autoclaved and stored in sterile containers (Figure 1).
Chunks of polyurethane foam stored in sterile containers.
After removing the surgical pack on the 2nd post-operative day, the maxillectomy cavity was inspected and cleaned (Figure 2). Chunks of polyurethane foam were cut (Figure 3) to create a piece that would snugly fit into the maxillectomy cavity, ensuring that the lower extent of the obturator was at the level of the hard palate (Figure 4).
Post-operative maxillectomy cavity.
Blocks of polyurethane foam cut to fit the maxillectomy cavity.
Polyurethane obturator in situ.
This procedure was demonstrated to the patients and their caregivers. They were advised to place the foam obturator during a meal and discard the same after a single use. During the rest of the day, the post-operative cavity was left open to allow for healing of the surgical site. Patients were also instructed to cleanse the cavity twice a day using a 50 cc syringe and warm saline.
Patients did not have much difficulty in using polyurethane foam except for having to discard the sponge after every meal. Following treatment completion, patients were referred to prosthodontists for definitive obturators. Even though this method's aesthetic appeal and the resulting speech quality were suboptimal, patients were comfortable using polyurethane foam as an alternative as it meant they could commence oral feeding early in the post-operative period, especially in edentulous patients in whom anchoring an obturator was always a challenge.
Discussion
During the second wave of the Covid-19 pandemic, in which there was an increase in post-coronavirus and concurrent mucormycosis cases, assessing and making a primary cast for mucormycosis patients became a logistical nightmare.
Generally, surgical and interim obturators were not used in urgent prosthodontic procedures during the Covid-19 era, and the fabrication of definitive obturators was deferred after assessing the risk–benefit ratio, especially in immunocompromised patients.Reference Pruthi, Parkash, Vijaya Bharathi, Jain, Gupta and Rai1 Making obturators for surgical defects caused by debridement in mucormycosis patients is challenging as an additional margin of tissues may need to be removed because of rapidly advancing fungal infection. Hence, delayed obturators are preferred in cases of maxillectomy performed for mucormycosis.Reference Mohamed, Mahesheswaran and Mohanty2 Given the safety precautions recommended during the Covid-19 pandemic, procedures resulting in aerosol generation were deferred.
For patients with Covid-19 and mucormycosis, making an obturator became challenging. In these patients, rehabilitation using a temporary obturator made of polyurethane foam helped alleviate acquired functional losses like swallowing difficulty and nasal regurgitation. Delaying the rehabilitation affected the quality of life of the post-maxillectomy patients because of smell and taste impairments, and functional losses.Reference Inbarajan, Natarajan, Thangarajan, Seenivasan, Banu and Kumar3 The foam obturator relieved patients from the extra burden of having a nasogastric tube. Edentulous patients benefitted the most from using this obturator as there was no need to anchor the obturator to the underlying tissue.
Polyurethane foam dressings like Lyofoam® have been in use since the 1970s, and were highly recommended for their cost-effectiveness and properties that make them ideal for wound dressing.Reference Williams4 In addition, polyurethane foam has been used as filling material in hollow bulb obturators to reduce the weight of the obturator in an easier and affordable manner.Reference Tanaka, Gold and Pruzansky5 One of the concerns of using polyurethane foam was the fluid and moisture absorption, which causes halitosis and post-operative wound site infection. This can be prevented by replacing the foam after every meal and cleansing the cavity on a daily basis. Sometimes, adherence of the polyurethane foam to the wound can cause some material to be left behind in the wound cavity, which can act as a foreign body; hence, caregivers are instructed to ensure that no foam material is left behind while removing the foam and during cleansing. Lastly, as polyurethane foam is inexpensive and freely available, this novel method can be used in low-income settings and emergencies like the post-coronavirus mucormycosis epidemic.
Conclusion
The Covid-19 pandemic gave physicians time-sensitive challenges, for which immediate alternatives to established care were required. A maxillary obturator made of high-density polyurethane foam is an innovative solution to rehabilitate maxillectomy patients in the immediate post-operative period.
Competing interests
None declared
