Prevalence of co-existent COVID-19-associated pulmonary aspergillosis (CAPA) and its impact on early mortality in patients with COVID-19-associated pulmonary mucormycosis (CAPM).

BACKGROUND: Data on mixed mould infection with COVID-19-associated pulmonary aspergillosis (CAPA) and COVID-19-associated pulmonary mucormycosis (CAPM) are sparse. OBJECTIVES: To ascertain the prevalence of co-existent CAPA in CAPM (mixed mould infection) and whether mixed mould infection is associated with early mortality (≤7 days of diagnosis). METHODS: We retrospectively analysed the data collected from 25 centres across India on COVID-19-associated mucormycosis. We included only CAPM and excluded subjects with disseminated or rhino-orbital mucormycosis. We defined co-existent CAPA if a respiratory specimen showed septate hyphae on smear, histopathology or culture grew Aspergillus spp. We also compare the demography, predisposing factors, severity of COVID-19, and management of CAPM patients with and without CAPA. Using a case-control design, we assess whether mixed mould infection (primary exposure) were associated with early mortality in CAPM. RESULTS: We included 105 patients with CAPM. The prevalence of mixed mould infection was 20% (21/105). Patients with mixed mould infection experienced early mortality (9/21 [42.9%] vs. 15/84 [17.9%]; p = 0.02) and poorer survival at 6 weeks (7/21 [33.3] vs. 46/77 [59.7%]; p = 0.03) than CAPM alone. On imaging, consolidation was more commonly encountered with mixed mould infections than CAPM. Co-existent CAPA (odds ratio [95% confidence interval], 19.1 [2.62-139.1]) was independently associated with early mortality in CAPM after adjusting for hypoxemia during COVID-19 and other factors. CONCLUSION: Coinfection of CAPA and CAPM was not uncommon in our CAPM patients and portends a worse prognosis. Prospective studies from different countries are required to know the impact of mixed mould infection.

Posterior nasal nerve neurectomy for the treatment of chronic rhinosinusitis with nasal polyposis: a randomized controlled trial.

BACKGROUND: Managing Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP) is always challenging due to the chronicity of the disease and its intractable course. Posterior nasal neurectomy (PNN) can be effective in alleviating symptoms of CRSwNP. MATERIALS AND METHODS: The study was conducted in a tertiary care referral hospital from August 2019 to April 2022. A total of 46 patients of CRSwNP were included (23 patients in the study and 23 in the control group). Patients in the study group underwent endoscopic sinus surgery (ESS) and PNN and patients in the control group with ESS. The symptoms and quality-of-life improvement were assessed at 1, 4, 12, and 24 weeks after the surgery. RESULTS: On intragroup analysis between the preoperative and postoperative scores (SNOT-22, RSDI and LK Score), we found a significant difference for each (p < 0.05). When the improvement of outcome scores was compared between the two groups, a significant difference was obtained for SNOT-22 and RSDI scores at 1 week and 4 weeks (p < 0.05). There was no significant difference found for the duration of surgery/complications between the two groups (p = 1.00). CONCLUSION: The PNN can be an effective add-on procedure in patients with CRSwNP in alleviating short-term control of the symptoms and the quality of life. A larger sample size with long-term follow-up may be required for a better understanding of the efficacy of the PNN in patients with CRSwNP.

Fabrication and optimization of extended-release beads of diclofenac sodium based on Ca++ cross-linked Taro (Colocasia esculenta) stolon polysaccharide and pectin by quality-by-design approach.

The present investigation was aimed to fabricate and optimize extended-release beads of diclofenac sodium based on an ion-cross-linked matrix of pectin (PTN) and taro (Colocasia esculenta) stolon polysaccharide (TSP) with 23 full factorial design. Total polysaccharide concentration (TPC), polysaccharide ratio (PR), and cross-linker concentration ([CaCl2]) were taken as independent factors with two levels of each. Initially, TSP was extracted, purified, and characterized. Fourier-transform infrared spectroscopy (FTIR) and Differential Scanning Calorimetry (DSC) showed drug-polymer compatibility. The study also revealed the significant positive effect of TSP on drug entrapment efficiency (DEE) and sustaining drug release. The response variables (DEE, cumulative % drug-release at 1, 2, 4, 6, and 10 h, release-constant, time for 50 % and 90 % drug release (T50%, T90%), release-similarity factor (f2), and difference factor (f1) were analyzed, and subsequently, independent fabrication variables were numerically optimized by Design-Expert software (Version-13; Stat-Ease Inc., Minneapolis). The optimized batch exhibited appreciable DEE of 88.5 % (± 2.2) and an extended-release profile with significantly higher T50%, T90%, and release-similarity factor (f2) of 4.7 h, 11.4 h, and 71.6, respectively. Therefore, the study exhibited successful incorporation of the novel TSP as a potential alternative adjunct polysaccharide in the pectin-based ion-cross-linked inter-penetrating polymeric network for extended drug release.

Endoscopic Tympanoplasty as an Alternative to Microscopic Tympanoplasty: A Comparative Study on Surgical Outcomes and patient satisfaction.

Background: Chronic otitis media treatment has evolved, with microscopic surgeries as the gold standard and endoscopic surgeries as a newer addition. Materials and Methods: This retrospective study includes 209 patients who underwent type 1 tympanoplasty, utilizing both endoscopic and microscopic techniques, between January 2019 and December 2022 at a tertiary care institute in India. The study aims to compare hearing outcomes, graft uptake, hospital stay, postoperative pain, and cosmesis between the two groups. Results: Mean AB gap closure was 17.09 + 5.98 dB in the endoscopic group and 16.74 + 5.05 dB in the microscopic group (P = 0.687). The duration of surgery was 79.26 ± 17.37 min in the Endoscopic group and 91.92 ± 15.35 min in the Microscopic group. (P = < 0.00001). The Endoscopic group experienced less post-operative pain, shorter hospital stay (P = < 0.00001, P = 0.0008), and exhibited better cosmetic outcomes (P = 0.00001) compared to the microscopic group. Conclusion: Endoscopic tympanoplasty is a better alternative to microscopic tympanoplasty, delivering comparable hearing outcomes, shorter surgical duration, improved pain scores, and better cosmesis. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04184-4.

Risk factors, mortality, and predictors of survival in COVID-19-associated pulmonary mucormycosis: a multicentre retrospective study from India.

OBJECTIVES: To compare COVID-19-associated pulmonary mucormycosis (CAPM) with COVID-19-associated rhino-orbital mucormycosis (CAROM), ascertain factors associated with CAPM among patients with COVID-19, and identify factors associated with 12-week mortality in CAPM. METHODS: We performed a retrospective multicentre cohort study. All study participants had COVID-19. We enrolled CAPM, CAROM, and COVID-19 subjects without mucormycosis (controls; age-matched). We collected information on demography, predisposing factors, and details of COVID-19 illness. Univariable analysis was used to compare CAPM and CAROM. We used multivariable logistic regression to evaluate factors associated with CAPM (with hypoxemia during COVID-19 as the primary exposure) and at 12-week mortality. RESULTS: We included 1724 cases (CAPM [n = 122], CAROM [n = 1602]) and 3911 controls. Male sex, renal transplantation, multimorbidity, neutrophil-lymphocyte ratio, intensive care admission, and cumulative glucocorticoid dose for COVID-19 were significantly higher in CAPM than in CAROM. On multivariable analysis, COVID-19-related hypoxemia (aOR, 2.384; 95% CI, 1.209-4.700), male sex, rural residence, diabetes mellitus, serum C-reactive protein, glucocorticoid, and zinc use during COVID-19 were independently associated with CAPM. CAPM reported a higher 12-week mortality than CAROM (56 of the 107 [52.3%] vs. 413 of the 1356 [30.5%]; p = 0.0001). Hypoxemia during COVID-19 (aOR [95% CI], 3.70 [1.34-10.25]) and Aspergillus co-infection (aOR [95% CI], 5.40 [1.23-23.64]) were independently associated with mortality in CAPM, whereas surgery was associated with better survival. DISCUSSION: CAPM is a distinct entity with a higher mortality than CAROM. Hypoxemia during COVID-19 illness is associated with CAPM. COVID-19 hypoxemia and Aspergillus co-infection were associated with higher mortality in CAPM.

A Review on the Nasal Microbiome and Various Disease Conditions for Newer Approaches to Treatments.

Introduction: Commensal bacteria have always played a significant role in the maintenance of health and disease but are being unravelled only recently. Studies suggest that the nasal microbiome has a significant role in the development of various disease conditions. Search engines were used for searching articles having a nasal microbiome and disease correlation. In olfactory dysfunction, dysbiosis of the microbiome may have a significant role to play in the pathogenesis. The nasal microbiome influences the phenotype of CRS and is also capable of modulating the immune response and plays a role in polyp formation. Microbiome dysbiosis has a pivotal role in the development of Allergic Rhinitis; but, yet known how is this role played. The nasal microbiome has a close association with the severity and phenotype of asthma. They contribute significantly to the onset, severity, and development of asthma. The nasal microbiome has a significant impact on the immunity and protection of its host. The nasal microbiome has been a stimulus in the development of Otitis Media and its manifestations. Studies suggest that the resident nasal microbiome is responsible for the initiation of neurodegenerative diseases like Parkinson's Disease.Materials and Methods: Literature search from PubMed, Medline, and Google with the Mesh terms: nasal microbiome AND diseases. Conclusion: With increasing evidence on the role of the nasal microbiome on various diseases, it would be interesting to see how this microbiome can be modulated by pro/pre/post biotics to prevent a disease or the severity of illness.

Endoscopic Repair of CSF Rhinorrhea: Our Experience at a Tertiary Centre.

Spontaneous or post-traumatic CSF (cerebrospinal-fluid) rhinorrhea occurs when there is a skull-base defect. In our study, we tried endoscopic approach, exclusively as surgical modality. To study feasibility of trans-nasal endoscopic approach for repair of skull-base defects and success rates at each anatomical subsite, with complications. Patients, who underwent endoscopic repair of CSF rhinorrhea between 2016 and 2019 were recruited into study. Details of investigative work-up, aetiology, surgery done, site of leak, number of surgical procedures done, post-operative complications and their management, success rate for each anatomical sub-site, was retrieved retrospectively and analyzed. All patients were initially managed with conservative measures before taking up for surgery. Eighteen-patients (male-11, female-7, mean age-40.3 years) with CSF rhinorrhea {spontaneous-5(27.7%), traumatic-13(62.3%)} were found. Sites of leak were cribriform-plate (CP), fovea-ethmoidalis (FE) and posterior-table of frontal-sinus (FS) in 8(44.4%), 5(27.7%) and 5(27.7%) respectively. Twelve (66.6%) patients had no postoperative complications. No patients with defects in CP had post-operative complication. Two (11.1%) patients with FS defect had meningitis, one (5.5%) patient with FS defect developed pneumocephalus. One (5.5%) patient developed frontal sinusitis at end of 4-months. Two (11.1%) patients, each with defects in FE and FS needed a revision repair on postoperative day 0 and 90-till date, none of the patients have any delayed procedure related complications or recurrences. Endoscopic repair of CSF leaks is the norm of the current day due to its minimally invasive nature. However, endoscopic repair of leaks through the frontal sinus were challenging and was associated with a high rate of complications.

Exclusive Endoscopic Approach in the Management of Sinonasal Inverted Papilloma.

Background: With the advancement in endoscopic endonasal surgeries, there has been a change in the surgical approach from the traditional open surgeries to the more conservative endoscopic endonasal approach for the management of sinonasal inverted papilloma. In the present study, we have shared our experience of endoscopic excision inverted papilloma involving the paranasal sinuses in a tertiary care hospital. Materials and methods: It is a retrospective case series of 28 patients who underwent endoscopic excision of inverted papilloma of paranasal sinus in a tertiary care hospital from April 2017 to October 2020. The medical records were retrospectively analyzed for the clinical, radiological, pathological, intraoperative and postoperative findings and later compared among the surgical approaches. Results: Of the total of 28 patients with inverted papilloma (3; Krouse 2 and 25; Krouse 3), 11(21.4%) patients were operated through endoscopic modified Denker, 8(39.3%) patients with endoscopic medial maxillectomy and 6(21.4%) patients with endoscopic sinus surgery. Patients who underwent modified endoscopic approach had lesser complications compared to the standard endoscopic procedures. Conclusion: Endoscopic excision of the sinonasal inverted papilloma can be a valid alternative to the open surgical approach, enabling complete clearance of the disease with a minimal complication rate. A large population with a long-term follow-up may be needed for a better understanding of the results. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03332-6.

Newborn Hearing Screening with Two-Step Protocol and Risk Factor Identification: Our Experience at a Tertiary Care Centre in Eastern India.

Objective: To estimate the prevalence of hearing loss and identify the high-risk factors among neonates with hearing loss. Methods: Retrospective study done on 1054 infants in a tertiary care centre in Eastern India from 2020 to 2021 and approved by the Institutional Ethics Committee. A two-step protocol is used for screening. In the well-nursed group, OAE and BOA were performed. In the case of REFER results for automated ABR following OAE evaluation in well-nursed babies, a detailed audiological evaluation was scheduled to be carried out using diagnostic ABR within one month of age. In the high-risk group, hearing screening includes OAE, BOA, and AABR evaluations. AABR evaluation was performed as a part of the screening protocol irrespective of the results of OAE screening as PASS or REFER. Results: In our study among 1053 neonates screened, 375 were in the risk category, and 679 were without risk factors. The overall prevalence of hearing loss in neonates was 22.78 per 1000 screened neonates and 56 per 1000 among high-risk neonates. In the high-risk group, we were able to identify 4 cases of Auditory spectrum neuropathy disorder with the use of AABR during 1st step of screening. In multivariate regression analysis, the risk factors for hearing loss identified were NICU stay (OR = 3.6, 95% CI = 1.1-12.03) and Craniofacial anomalies (OR = 55.37, 95% CI = 16.48- 186.01). Conclusion: Early neonatal screening helps in the detection, intervention, and rehabilitation of hearing loss. The use of AABR in risk infant screening enhanced the chance of detection of auditory spectrum neuropathy disorder (ASND) cases. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03723-3.

Evaluation of Cassia fistula seed galactomannan as tablet-binder in formulation of diclofenac sodium-loaded monolithic matrix tablet.

The present study aimed to evaluate Cassia fistula seed galactomannan (CFSG) as a tablet-binder in the formulation of a monolithic matrix tablet using diclofenac sodium as a model drug. Initially, CFSG was extracted and purified from the seeds of the Cassia fistula tree and then screened for phytochemicals. Native CFSG was characterized with polysaccharide content determination, monosaccharide composition analysis, elemental analysis, FTIR, solid-state 13C NMR, molecular weight, zeta potential, DSC, TGA-DTA, XRD, viscosity, pH and surface tension, rheology, SEM and acute oral toxicity study. Prior to formulation, the drug-CFSG compatibility was checked by FTIR, DSC, and XRD. Diclofenac sodium-loaded granules were prepared by the wet granulation method and evaluated for various granule properties. Finally, granules were compressed into tablets and evaluated for binding and other tablet properties. The granules showed to have optimum micromeritic properties. Tablet hardness and friability were found to be approximately 7 kg/m2 and 0.3 %, respectively, which substantiate the excellent binding capacity of CFSG. Other tablet properties were also found to be within the Pharmacopoeial compliance limit. The tablets with a minimum concentration of CFSG (2.5%w/w) as binder showed appreciable mechanical strength and faster drug release, which ratifies CFSG as an alternative tablet binder.

Comparing accuracy of cochlear measurements on magnetic resonance imaging and computed tomography: A step towards radiation-free cochlear implantation.

Objective: Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are commonly employed in pre-operative evaluation for cochlear implant surgery. However, with a decrease in the age of implantation, even minor radiation exposure can cause detrimental effects on children over their lifetime. The current study compares different cochlear measurements from CT and MRI scans and evaluates the feasibility of using only an MRI scan for radiological evaluation before cochlear implantation. Methods: A longitudinal observational study was conducted on 94 ears/47 children, employing CT and MRI scans. The CT and MRI scan measurements include, A value, B value, Cochlear duct length (CDL), two-turn cochlear length, alpha and beta angles to look for cochlear orientation. Cochlear nerve diameter was measured using MRI. The values were compared. Results: The mean difference between measurements from CT and MRI scans for A value, B value, CDL, and two-turn cochlear length values was 0.567 ± 0.413 mm, 0.406 ± 0.368 mm, 2.365 ± 1.675 mm, and 2.063 ± 1.477 mm respectively without any significant difference. The alpha and beta angle measures were comparable, with no statistically significant difference. Conclusion: The study suggests that MRI scans can be the only radiological investigation needed with no radiation risk and reduces the cost of cochlear implant program in the paediatric population. There is no significant difference between the measurements obtained from CT and MRI scans. However, observed discrepancies in cochlear measurements across different populations require regionally or race-specific standardized values to ensure accurate diagnosis and precision in cochlear implant surgery. This aspect must be addressed to ensure positive outcomes for patients.

Genetics Landscape of Nonsyndromic Hearing Loss in Indian Populations.

Congenital nonsyndromic hearing loss (NSHL) has been considered as one of the most prevalent chronic disorder in children. It affects the physical and mental conditions of a large children population worldwide. Because of the genetic heterogeneity, the identification of target gene is very challenging. However, gap junction ß-2 ( GJB2 ) is taken as the key gene for hearing loss, as its involvement has been reported frequently in NSHL cases. This study aimed to identify the association of GJB2 mutants in different Indian populations based on published studies in Indian population. This will provide clear genetic fundamental of NSHL in Indian biogeography, which would be helpful in the diagnosis process.

Presentation of potential genes and deleterious variants associated with non-syndromic hearing loss: a computational approach.

Non-syndromic hearing loss (NSHL) is a common hereditary disorder. Both clinical and genetic heterogeneity has created many obstacles to understanding the causes of NSHL. The present study has attempted to ravel the genetic aetiology in NSHL progression and to screen out potential target genes using computational approaches. The reported NSHL target genes (2009-2020) have been studied by analyzing different biochemical and signaling pathways, interpretation of their functional association network, and discovery of important regulatory interactions with three previously established miRNAs in the human inner ear as well as in NSHL such as miR-183, miR-182, and miR-96. This study has identified SMAD4 and SNAI2 as the most putative target genes of NSHL. But pathogenic and deleterious non-synonymous single nucleotide polymorphisms discovered within SMAD4 is anticipated to have an impact on NSHL progression. Additionally, the identified deleterious variants in the functional domains of SMAD4 added a supportive clue for further study. Thus, the identified deleterious variant i.e., rs377767367 (G491V) in SMAD4 needs further clinical validation. The present outcomes would provide insights into the genetics of NSHL progression.

Management of Lingual Thyroid with Second Thyroid Anomaly: An Institutional Experience.

Patients diagnosed with Lingual thyroid (LT) may have second thyroid anomaly (STA).Given rarity of dual ectopics/anomalies, standardized management recommendations are lacking. We aimed to describe our experience in management of LT with STA and suggest a management algorithm. We conducted a retrospectivechart review of patients diagnosed with LT between Jul-2013 and Dec-2019. Data regarding demographics, clinical presentation, endocrine-profile, associated STA treatment received, and outcomes were collected and analyzed. Eight patients (female-7 cases, male-1 case, adult-4 cases, children-4 cases, mean age-18.1 years, range 6-43 years) with LT were identified. Four(50%) cases had STA in addition to LT (thyroglossal cyst in two-cases, sublingual thyroid in one-case and sub-mental thyroid in one-case) and presented as neck mass. Diagnosis was confirmed with flexible-nasopharyngoscopy,ultrasonography,thyroid-scintigraphy and computed-tomography. Ectopic thyroid(s) was/were only functional thyroid gland with absence of normal thyroid in all cases. Two- cases had symptomatic for LT and were managed by coblation assisted excision of LT in one and I131 ablation in one-case.All adult patients were hypothyroidand received thyroxin.All pediatric cases were euthyroidand received no surgical intervention for LT.Three patients required surgery for STA; Sistrunk surgery in two and excision of submental thyroid in one. All cases were asymptomatic. These results were utilized to suggest a management algorithm for LT with STA. LT patients with STA are more symptomatic and required more surgical interventions in compare to isolated LT. When appropriate, excision of STA with/without intervention for LT and thyroxin is advocated as the treatment modality of choice in LT patients with STA.

Prevalence and Predictors of Malignancy in Contralateral Thyroid Lobe in Patients Undergoing Completion Thyroidectomy.

(1) To determine prevalence of malignancy in contralateral lobe (CL) in patients undergoing completion thyroidectomy (CT) and to study complications of CT. (2) To analyze clinical, ultrasonography(USG) findings and histopathological features of the tumor in ipsilateral lobe (IL) that could predict malignancy in CL. Retrospective chart review of 40-patients who first underwent hemi-thyroidectomy for fine-needle-aspiration (FNA) diagnosed benign lesions followed by CT between September-2017 and November-2019. Histopathology reports from both surgeries, along with patient characteristics and USGfeatures of initial hemi-thyroid lobe were reviewed. Thirty-two (80%) of the 40 patients were female. Mean age of presentation was 38.2 years (Range = 19-61years). Malignancy was found in 22(55%) contralateral-lobes of 40 completion thyroidectomies performed. Multi-focality of tumor in first surgery was only factor with significant association with presence of malignancy in CL (OR = 5.53, 95% CI 1.01-30.35, p = 0.048).In terms of USG-findings, most common suspicious feature in IL was peripheral/rim calcification, with TIRADS ≥ 4 was present in 19 patients but none of features could significantly predict bilateral disease. Three (7.5%) patients developed permanent unilateral recurrent-laryngeal-nerve (RLN) palsy (2-following initial surgery and 1-following CT). Fourteen (35%) patients developed hypoparathyroidism following CT of whom 12 were symptomatic and 4(10%) proceeded to permanent hypoparathyroidism. There were no other major complication following CT. Multifocality in initial hemithyroidectomy specimen was most frequently associated with malignancy in CL. Preoperative TIRADS ≥ 4 of IL may be considered a risk factor for bilateral malignancy. CT may be performed in FNA misdiagnosed thyroid cancers as there is high prevalence(56%) of disease in CL. CT is safe and it eradicates disease in CL.

Analysis of Pattern of Laryngotracheal Invasion by Papillary Thyroid Carcinoma and Their Management: Our Experience.

To analyse the pattern of laryngotracheal invasion (LTI) by papillary-thyroid-carcinoma (PTC) and outcomes of their management. We undertook a retrospective chart review to study patterns of LTI by PTC and to evaluate outcomes of surgical modalities used to treat PTC with LTI. Out of 246cases of PTC, 26-cases had LTI (male-12, female-14, mean-age-55.6 years, range 42-73 years). Common clinical presentation were neck swelling, respiratory distress/stridor and vocal cord paralysis in 100%, 8 (30.8%) and 10 (38.5%) cases respectively. PTC was staged according to AJCC-TNM staging system (T4a-24, T4b-02, N1a-12, N1b-14, M0-25, and M1-01). CT-scan showed obvious LTI and tracheal narrowing in 11(42.3%) and 18(69.2%) cases respectively. All cases underwent total thyroidectomy with central-compartment-clearance. Unilateral and bilateral lateral-neck-dissection was performed in 08 and 06cases respectively. Pattern of Intra-operative LTI were as follows: trachea-13cases, trachea and cricoid-05cases, thyroid cartilage-6cases, trachea, cricoid and thyroid cartilage-2 cases and intra-luminal involvement in 4cases. Modified Shin's staging was used to stage LTI. LTI were superficial, deep-extra-luminal and intra-luminal in 13, 09 and 04cases respectively. LTI was managed by shave-excision, window-resection of trachea, sleeve-resection of trachea and anastomosis, partial laryngectomy and total-laryngectomy in 13,02,04,05 and 2 cases respectively. All patients received radio-active-iodine (RAI) and TSH-suppression-therapy post-operatively. Mean follow-up period was two-years (range 18-30 months). One-case had radio-iodine non-avid local recurrence with lung metastases one-year post-operatively. Shave-excision is adequate for tumours not infiltrating into outer perichondrium. Tracheal-resection and total/partial laryngectomy may be required in cases with laryngo-tracheal cartilage or intra-luminal involvement. Adequate surgical excision along with postoperative RAI and TSH-suppression-therapy gives good loco-regional disease control in PTC with LTI.

Management of Covid Associated Mucormycosis of Mandible: A Mountain Beneath a Molehill-A Lesson Learnt.

The opportunistic infection of post-Covid associated mucormycosis has been reported globally; however, it has reached alarming proportions in India. Mucormycosis of the mandibular region is rare, and only a few cases have been reported to date. Covid associated mucormycosis has not been reported in the literature before, and we are the first to report them. We report two patients who presented with tooth loosening with pus discharge a few weeks following recovery from Covid infection. After tooth extraction adjacent necrotic bony specimen was sent for calcofluor potassium hydroxide mount, which was found positive for broad pauciseptate hyphae. Although CT scan imaging demonstrated the involvement of a mandible segment, we found a much more extensive involvement in both cases during resection. There was intramedullary spread of the mucormycosis throughout the inferior alveolar canal, with pus discharge and foul odor. The management of covid associated mandibular mucormycosis consists of surgical debridement with antifungal therapy and control of the underlying disease. It became challenging because the radiological extent of the disease was different from the definite clinical extension of the lesion found during surgery. The authors recommend surgeons adopt a flexible approach during surgery to plan resection depending on the clinical judgment and not rely entirely on CT scans. And the reconstruction of the mandible will follow as per the extent of excision.

Prevalence of Skip Metastases to Cervical Lymph-Nodes in Oral cavity Cancer in Eastern India-an observational study.

To determine the prevalence of skip metastases in Oral-squamous-cell-carcinoma (OSCC). This prospective observational study was carried out on 100-cases of biopsy proven OSCC who underwent surgical treatment for the primary tumor along with neck dissection (ND). Data regarding depth of invasion (DOI) by primary tumor, perineural-invasion, lymphovascular-invasion, presence of metastatic-lymph-node (level, size, number and extranodal-extension) were collected from histopathology reports and were analyzed. Out of 100-cases, 73-were-male and 27-were-female. Mean age was 49.5 ± 12.3 years (range 24-4 years). Common subsites of tumor were buccal-mucosa, tongue and lower-alveolus in 40, 37 and 14% respectively. Pathological staging of tumor were stage-I, stage-II, stage-III, stage-IVa and stage-IVb in 22, 14, 25, 22 and 15% cases respectively. Preoperative neck staging was cN0 in 50 necks (47.2%) and cN+ in 56 necks (52.8%). In 100-patients 106-NDs (unilateral-94 and bilateral-6) were performed. Type of NDs were Supraomohyoid, extended-Supraomohyoid and modified radical neck-dissection in 23,07and76 cases respectively. Prevalence of cervical lymph node metastases was 36% (pN + necks). Among 36pN + patients; 25 (69.4%) cases, 20 (55.5%) cases, 9 (25%) cases, 4 (11.1%) cases, 2 (5.5%) cases had metastases to level-I, II, III, IV and V respectively. Skip-metastases was present in four-cases {level-IIb:one-case (2.78%), level-III: two-cases (5.5%) and level-V:one-case (2.78%)}. No-skip-metastasis to level-IV was noticed. All-four-cases of skip-metastases were from advance cases of squamous-cell-carcinoma of tongue with DOI > 5 mm. Skip-metastases to levels IIb, IV and V are uncommon in cases of OSCC. Most of the metastasis in our study was noted to levels I, II and III in a predictable fashion. Thus, extensive ND can be avoided in patients to prevent complications and morbidities associated with the same.

Altered Nasal Microbiome in Atrophic Rhinitis: A Novel Theory of Etiopathogenesis and Therapy.

Background: Atrophic rhinitis (AtR) is a chronic nasal condition with polygenic and polybacterial etiology. We investigated the clinical outcomes of honey therapy and the associated nasal microbiome in AtR. Methods: For eight weeks, a nonrandomized control trial using a nasal spray of 10% manuka honey and saline on the right and left sides of the nose was conducted on 19 primary AtR patients. A nasal endoscopy was performed and a mucosal biopsy were taken before and after the intervention. Five of the nineteen patients were selected for microbiome and GPR43 expression studies. Results: We used manuka honey to describe an effective prebiotic treatment for atrophic rhinitis. There were nine males and ten females with an average (±SD) age of 33.8 (±10.7) years. Endoscopic scores and clinical symptoms improved in honey-treated nasal cavities (p < 0.003). There was a significant decrease in inflammation, restoration of mucus glands, and increased expression of GPR43 in the nasal cavities with honey therapy. The nasal microbiome composition before and after treatment was documented. Particularly, short chain fatty acid (SCFA) producers were positively enriched after honey therapy and correlated with improved clinical outcomes like nasal crusting, congestion, and discharge. Conclusion: Our approach to treating AtR patients with manuka honey illustrated effective clinical outcomes such as (1) decreased fetid smell, (2) thickening of the mucosa, (3) decreased inflammation with healed mucosal ulcers, (4) increased concentration of the mucosal glands, (5) altered nasal microbiome, and (6) increased expression of SCFA receptors. These changes are consequent to resetting the nasal microbiome due to honey therapy.