Imaging spectrum of rhino-orbital-cerebral mucormycosis secondary to COVID-19 infection: a reporting checklist.

In recent times, India has been in the midst of a notifiable epidemic of mucormycosis (a rare angio-invasive fungal infection), within the ongoing global coronavirus disease 2019 (COVID-19) pandemic. Epidemiological studies have reported the estimated prevalence of mucormycosis to be around 70 times higher in India as compared to the global data, even in the pre-COVID era. However, in the last 3 months, our city witnessed an unprecedented surge in cases of post-COVID-19-associated rhino-orbital-cerebral (ROC) mucormycosis. This pictorial review aims to illustrate the entire imaging spectrum of mucormycosis in the head-neck-face region. Along with the usual sites (nose, paranasal sinuses, orbits), this disease also involves the skull base, palate, temporal bone, and deep neck spaces. Many cases also demonstrated morbid and, at times, fatal intracranial and neurovascular complications. This review also aims to provide a structured reporting template that will prove useful to the radiologists interpreting imaging studies of ROC mucormycosis.

Sinonasal Anatomy.

It is imperative for all imaging specialists to be familiar with detailed multiplanar computed tomography imaging anatomy of the paranasal sinuses and adjacent structures. This article reviews, in brief, the radiologically relevant embryology of the sinonasal region and discusses the imaging anatomy of the nasal cavity and paranasal sinuses. Radiologists should understand the importance and clinical implications of identifying the numerous anatomic variations encountered in this region and prepare a structured report that provides a surgical road map to the referring clinician.

A Proposed Grading System and Experience of COVID-19 Associated Rhino Orbito Cerebral Mucormycosis from an Indian Tertiary Care Center.

Mucormycosis is an opportunistic fungal infection. India faced an unprecedented increase in patients with post coronavirus disease 2019 (COVID-19) associated rhino-orbito-cerebral mucormycosis (ROCM). This study proposes a grading system which correlates the extent of the disease with the management plan. An observational study was conducted January 2021-June 2021. We identified 65 patients. Eleven patients had mild disease, 27 patients had moderate, 16 patients were severe and 11 patients were graded as very severe. The management was planned based on this grading system. Early diagnosis, aggressive surgical debridement and antifungal drug therapy is the key to improve survival in ROCM. Procedures such as endoscopic orbital clearance, sublabial maxillectomy, and modified endoscopic Denkers (MED) approach facilitate access and surgical debridement. The new grading system proposed assists in planning the approach and extent of surgical debridement.

Deossification of the Otic Bone in High Pressure CSF Otorhinorrhea: A New Radiological Finding.

To highlight a new radiological feature in a patient with labyrinthine malformation presenting with bilateral spontaneous high pressure cerebrospinal fluid (CSF) otorhinorrhea. Study design-retrospective case review. Setting-academic, tertiary cochlear implant center. A cochlear implantee with Incomplete Partition Defect (Type 1) presented with meningitis and CSF otorhinorrhea for which she initially underwent medical treatment. High resolution computed tomography (HRCT) of the temporal bone with CT cisternography was performed for identifying the site of the CSF leak. HRCT and CT cisternography revealed a defect in the region of the stapes foot plate and marked thinning/deossification of the cochlear promontory. These two findings were absent in the pre-implant imaging of the patient done 3 years ago. Surgery by endaural approach was undertaken to close the site of CSF leak. Intraoperatively, marked thinning of the cochlear promontory was observed, corresponding to 'blue lining' of the labyrinth in otologic surgery. This intraoperative finding indicating high intralabyrinthine CSF pressure correlated well with the imaging findings. Primary surgical repair resulted in successful CSF leak closure followed by theco-peritoneal shunting to prevent recurrence of the leak. The patient is using her cochlear implant and doing well with auditory verbal therapy. She is asymptomatic till date. Thinning and deossification of the otic capsule on HRCT is an important indicator of high CSF pressure in patients with labyrinthine malformations. Our case study highlights the need for heightened radiological and clinical vigilance in this subgroup of patients to predict complications and ensure prompt intervention.

Surgical complications and their management in cochlear implantees less than 5 years of age: The KEMH Pune experience.

OBJECTIVE: To evaluate the incidence of surgical complications of cochlear implantation and their management at K.E.M. hospital Pune. METHODS: It was a retrospective and prospective observational study conducted from February 2006 to December 2015 in the paediatric age group of 12 months to 5 years (213 cases). The complications were divided into major and minor groups based on the classification proposed by Cohen and Hoffman. RESULTS: The mean age of implantation was 3.03 years (ranged from 1 to 4.11 years). Sixteen patients had complications. The overall incidence of complications was 7.51% which comprised of major (2.34%) and minor (5.16%) complications. The commonest major complications were flap-related issues and the commonest minor complication was facial paresis. DISCUSSION: The results of our study were compared with similar studies conducted in the past. All surgical complications were treated conservatively or surgically with success. CONCLUSIONS: Cochlear implantation is the safe procedure in children between the age group of 12 months and less than 5 years.

Bilateral Non-Hodgkin's Lymphoma of the Temporal Bone: A Rare and Unusual Presentation.

Primary lymphoma of the temporal bone is an unusual finding in clinical practice and bilateral affection is even more rare. To the best of our knowledge, there are no reports of bilateral primary temporal bone lymphoma without middle ear involvement in the English medical literature so far. We report, for the first time, a case of primary lymphoma involving both temporal bones which presented with left-sided infranuclear facial palsy. A combination of contrast enhanced magnetic resonance imaging (MRI) and high resolution computed tomography (HRCT) was used to characterize and to map the extent of the lesion, as well as to identify the exact site of facial nerve affection. An excision biopsy and immunohistochemistry revealed diffuse large B-cell non-Hodgkin's lymphoma (DLBCL). Whole body fluorodeoxyglucose (FDG) positron emission tomography-computed tomography study (PET-CT) was performed to stage the disease. The patient was treated with chemotherapy and radiation therapy and is now on regular follow-up. The patient is alive and asymptomatic without disease progression for the last twenty months after initial diagnosis.

Bilateral cochlear implantation under local anaesthesia in a young adult - A case report.

OBJECTIVE: Cochlear implantation is routinely performed under general anaesthesia in most centres in the world. There have been reports of this surgery being performed under local anaesthesia and sedation for unilateral cochlear implantation. Our case study reports the first bilateral cochlear implantation carried out under local anaesthesia with sedation. This paper outlines the protocol used and discusses the challenges and advantages of the procedure being performed under local anaesthesia. CASE STUDY: A 28-year-old female with a history of multidrug-resistant tuberculosis presented with bilateral severe to profound sensorineural hearing loss. On evaluation, she was found to be a suitable candidate for cochlear implantation. However, she was clinically unfit to undergo the surgery under general anaesthesia. After counselling the patient, the decision to undertake the procedure under local anaesthesia was made. The procedure took 105 min and was uneventful. The patient was discharged the next day Conclusion: In the hands of an experienced surgeon and anaesthesiology team, bilateral cochlear implantation is possible under local anaesthesia. Patient motivation and cooperation are extremely important for the procedure to be done under local anaesthesia. This is an option for patients needing cochlear implantation who are medically unfit for general anaesthesia.

Normal Anatomy and Anatomic Variants of the Paranasal Sinuses on Computed Tomography.

It is imperative for all imaging specialists to be familiar with detailed multiplanar CT anatomy of the paranasal sinuses and adjacent structures. This article reviews the radiologically relevant embryology of this complex region and discusses the region-specific CT anatomy of the paranasal sinuses and surrounding structures. Radiologists also need to know the clinical implications of identifying preoperatively the numerous anatomic variations encountered in this region and prepare a structured report according to the expectations of the referring clinician.

Role of HRCT and MRI of the Temporal Bone in Predicting and Grading the Degree of Difficulty of Cochlear Implant Surgery.

This study proposes a grading system based on a 10-point scoring chart of high resolution computed tomography (HRCT) and magnetic resonance imaging (MRI) imaging findings in patients being assessed preoperatively for cochlear implantation. This system helps in objectively assessing the degree of difficulty of the surgical procedure and alerts the surgeons to any potential intraoperative complications. This is a prospective study carried out at a tertiary referral center where 55 patients with bilateral profound sensorineural hearing loss were evaluated by HRCT and MRI and subsequently underwent cochlear implantation. HRCT examinations were performed on a 64 slice multidetector CT scanner. MRI examinations were performed on a 3.0 Tesla MRI scanner. A 10-point scoring chart was devised based on specific imaging findings and all patients were assigned potential difficulty scores (PDS) based on HRCT and MRI findings. Surgical times were documented in each case and each imaging point on the scoring chart was correlated with the surgical times. Eight out of theó ten points in the scoring chart proved to be statistically significant in predicting the degree of difficulty of the surgical procedure. After grading the pre-operative imaging examinations based on the 10-point scoring chart we concluded that patients who have PDS between 0 and 3 (Grade 1) have uneventful and uncomplicated surgery with the lowest intraoperative times. Patients with PDS between 4 and 7 alert the surgeon to moderate surgical difficulty and longer intraoperative times. PDS of 8 and above indicate prolonged and difficult surgery.

Pediatric synovial sarcoma in the retropharyngeal space: a rare and unusual presentation.

Synovial sarcomas in the head and neck are extremely rare tumors, especially in the pediatric population. 3-5% of synovial sarcomas occur in the head and neck region displaying varied imaging and histopathological features resulting in frequent misdiagnosis. These tumors have a poor prognosis; hence early diagnosis and accurate classification based on imaging, histopathology, and immunohistochemistry are critical for prompt treatment. To the best of our knowledge, imaging findings of pediatric retropharyngeal lipomatous synovial sarcoma have not been reported to date in English medical literature. We report, for the first time, a rare case of retropharyngeal lipomatous synovial sarcoma in a ten-year-old child and discuss the case-specific imaging findings in our patient using magnetic resonance imaging and computed tomography.

Case report - biofilm infection of a cochlear implant.

One of the most dreaded complications after cochlear implantation is infection. These infections are a challenge due to lack of any data regarding optimal methods of investigation and management. More often than not, these patients have to undergo explantation and revision surgery. This paper presents a case report and literature review which focuses on the role of antibiotics and the need for early explantation in most biofilm-related infections of cochlear implants.

Role of magnetic resonance imaging in cholesteatoma: the Indian experience.

The objectives are to evaluate role of magnetic resonance imaging (MRI) in diagnosis of cholesteatoma and correlate imaging findings with intraoperative findings, and to emphasize of role of imaging in the follow-up of postoperative patients for differentiating residual/recurrent cholesteatoma from granulation/inflammatory tissue. In this prospective study, 31 patients were evaluated with a specific MRI protocol and high resolution computed tomography of the temporal bones. These included patients with a strong suspicion of having a cholesteatoma on clinical examination and postoperative cases on clinical follow up. Based on specific MRI findings, presence of cholesteatoma was reported in 17 out of 31 patients. All 31 patients underwent surgery and 19 patients had confirmed intraoperative cholesteatoma. This study shows high sensitivity of a specific sequence based MRI examination in detection of cholesteatoma and in differentiating cholesteatoma from postoperative inflammatory/granulation tissue. To the best of the author's knowledge, this is the first such study performed in the Indian Asian population.

Infranuclear facial palsy: importance of imaging the geniculate fossa.

OBJECTIVE: To highlight the importance of imaging the geniculate fossa in patients with solitary infranuclear facial palsy. STUDY DESIGN: Prospective. SETTING: Tertiary referral center. ELIGIBILITY CRITERIA: Patients with solitary infranuclear facial palsy sent for imaging. INTERVENTION: Diagnostic. MAIN OUTCOME MEASURE: Imaging specifics concerning high-resolution computed tomography (HRCT) and magnetic resonance imaging (MRI) are described in detail for evaluation of the intratemporal part of the facial nerve with special focus on the geniculate fossa. RESULTS: Normal appearances of the geniculate fossa on HRCT and MRI and its normal anatomic variant, that is, dehiscence of the overlying bone are described. Imaging findings in a range of pathologies involving the geniculate fossa in a clinical setting of infranuclear facial nerve palsy is demonstrated. These include infections (tuberculosis), trauma, schwannoma, hemangioma, meningioma, and perineural spread of parotid malignancy. CONCLUSION: The geniculate fossa is a small bony hiatus in the temporal bone and is situated at the junction of the labyrinthine and the tympanic segments of the intratemporal facial nerve canal. It houses important neural structures and is best visualized by a combination of HRCT and high-resolution MRI examination of the temporal bone. It is therefore imperative for imaging specialists to be familiar with the normal appearance of this structure on HRCT and MRI examinations of the temporal bone as subtle imaging findings involving the geniculate fossa can be indicators of a variety of abnormalities.

Extracochlear electrode extrusion.

Extracochlear electrode extrusion is a potentially under-recognized complication of cochlear implantation. As the age of implantation becomes younger, electrode extrusion is of concern due to future skull growth. Extrusion of several electrodes may compromise performance and thus require surgical reinsertion of the electrodes. Almost 60% of patients with electrode extrusion have required revision surgery. This paper presents a case report and literature review which discusses factors which contribute to electrode extrusion and emphasizes the need for a high degree of suspicion in certain situations. Surgical steps such as electrode fixation techniques are highlighted in order to attempt to reduce the occurrence of this complication.

Proboscis lateralis with ipsilateral sinonasal and olfactory pathway aplasia.

Proboscis lateralis is a rare craniofacial malformation characterized by absence of nasal cavity on one side with a trunk-like nasal appendage protruding from superomedial portion of the ipsilateral orbit. High-resolution computed tomography and magnetic resonance imaging are extremely useful in evaluating this congenital condition and the wide spectrum of associated anomalies occurring in the surrounding anatomical regions and brain. We present a case of proboscis lateralis in a 2-year-old girl with associated ipsilateral sinonasal aplasia, orbital cyst, absent olfactory bulb and olfactory tract. Absence of ipsilateral olfactory pathway in this rare disorder has been documented on high-resolution computed tomography and magnetic resonance imaging by us for the first time in English medical literature.