Maxillary osteomyelitis secondary to mucormycosis, a sequel of COVID-19: a clinical case report

Introduction: One of the consequences of COVID-19 is the incidence of mucormycosis in the jaws and subsequent osteomyelitis in patients with undiagnosed or uncontrolled comorbidities, such as diabetes mellitus and associated immunosuppression. Case Report: A 52-year-old male patient with a history of COVID-19 two months ago presented a painful ulcerative lesion of insidious onset in the palatal raphe measuring approximately 2 mm. He referred to numbness of the palatal region of one month of evolution. During the physical examination, purulent content, multiple pustules in the anterior maxillary buccal mucosa, and mobility of upper anterior teeth were observed. The CT revealed isodense bilateral images in maxillary and ethmoidal sinuses, bone sequestrations, and partial loss of anterior vestibular cortical bone. Laboratory tests revealed no abnormality, except for HbH1c: 10.2gr/dl. The patient was hospitalized for control of newly diagnosed diabetes mellitus. Maxillary incisional biopsy was performed, and microscopic analysis showed a mixed inflammatory infiltrate, fibrin deposits with eosinophilic and birefringent ribbon-like hyphae, branched at right angles, compatible with maxillary osteomyelitis secondary to mucormycosis. The treatment started with antifungal and intravenous antibiotics, followed by surgical cleaning under general anesthesia. The patient progressed favorably. Conclusion(s): Immunosuppression resulting from COVID-19 and/or uncontrolled systemic diseases can condition the appearance of rare opportunistic microorganisms causing infections such as mucormycosis. Early diagnosis and treatment make a difference in the morbidity and mortality of patients.

A baby girl with TBX1 haploinsufficiency who died after elective cardiac repair surgery due to suspected enteroviral meningitis

Introduction: TBX1 haploinsufficiency is an inborn error of immunity with the phenotype of DiGeorge Syndrome. DiGeorge Syndrome has variable immunodeficiency associated with grade of thymic hypoplasia ranging from mild with no infections to severe requiring thymus implant. Enterovirus is an example of an opportunistic infection that can be fatal in these patients. Case Presentation: A 1 year old girl with TBX1 haploinsufficiency complicated by Tetralogy of Fallot, pulmonary atresia, high arched palate, and vesicovaginal fistula presented for elective cardiac repair surgery from another country due to failure to thrive and cyanosis. She had no prior infectious history but was on sulfamethoxazole-trimethoprim for prophylaxis. She was asymptomatic with a negative COVID test but no other infectious studies performed. Immediately postoperatively, she was febrile and nasal respiratory viral panel was positive for rhinovirus/enterovirus with increased procalcitonin and leukocytosis with left shift. She decompensated with multi-organ failure and cardiac arrest on postoperative day two. She was cannulated to veno-arterial extracorporeal membrane oxygenation (ECMO). Pre-operatively, she had a normal absolute lymphocyte count. No thymus tissue was observed in surgery. She had profound CD3 lymphopenia to 130 cells/cmm when critically ill. Enteroviral meningitis was suspected as no infectious, cardiac, or other pathology could be identified causing decompensation. Enteroviral serum polymerase chain reaction (PCR) test was negative while lumbar puncture deferred due to clinical status. She was treated with immunoglobulin. Offlabel investigational drug pocapavir was considered but deferred to patient's irreversible neurological status. The patient was disconnected from ECMO and expired. Discussion(s): Though we cannot confirm that this patient had enteroviral meningitis, invasive enteroviral infections are associated with elevated transaminases, coagulopathy, and seizures all present in our patient. There has also been reported negative serum enteroviral PCR but positive CSF enteroviral PCR in an immunodeficient patient. Additionally, this case highlights the importance of immunologic evaluation in patients with DiGeorge Syndrome and questions if asymptomatic viral screening for viruses like enterovirus should be considered pre-operatively in patients with inborn errors of immunity. This case highlights potential treatment options for invasive enteroviral infections in patients with inborn errors of immunity: high dose immunoglobulin, fluoxetine, and pocapavir.Copyright © 2023 Elsevier Inc.

A Systematic Review of the Efficacy of Haemostatic Interventions in Primary Cleft Palate Repair.

OBJECTIVE: To evaluate the effectiveness of adrenaline infiltration, topical adrenaline, systemic tranexamic acid, fibrin tissue sealants and alginate-based topical coagulants at reducing blood loss and post-operative bleeding in primary cleft palate repair. DESIGN: Systematic review according to PRISMA-P guidelines, using Covidence systematic review software to facilitate 3-stage screening and data extraction by two reviewers. SETTING: Academic cleft surgery center. INTERVENTIONS: Any peri-operative intervention to reduce intra-operative and post-operative bleeding. MAIN OUTCOME MEASURES: Estimated blood loss, rate of post-operative bleeding, rate of return to theatre for haemostasis. RESULTS: Sixteen relevant studies were identified, with a total of 1469 study participants. Nine studies examined efficacy of infiltrating vasoconstrictors and all concluded that 1:100,000-1:400,000 adrenaline infiltration reduced intra-operative blood loss, to the range of 12-60 ml. Secondary bleeding and re-operation for haemostasis were uncommon. Tranexamic acid was studied in five randomised controlled trials, two of which demonstrated a significant reduction in blood loss compared to a control group. Use of fibrin and gelatin sponge products was examined in 3 studies, all of which reported no or minimal bleeding, but did not have quantifiable outcome measures. CONCLUSIONS: Infiltration with vasoconstricting agents, administration of systemic tranexamic acid and application of fibrin sealants have a well-studied and favorable safety profile in pediatric cases, and likely contribute to the relatively low incidence of post-operative bleeding and intra-operative blood loss in primary cleft palate repair.

Angioedema induced by angiotensin-converting enzyme inhibitors: An analysis of hospitalizations during the covid-19 pandemic.

BACKGROUND: The pathogenesis of angioedema induced by angiotensin-converting enzyme inhibitors is based on the accumulation of bradykinin as a result of angiotensin-converting enzyme blockade. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) binds to the angiotensin-converting enzyme 2 receptor, which may inhibit its production and thereby lead to an increase in bradykinin levels. Thus, SARS-CoV-2 infection may be a likely trigger for the development of angioedema. AIMS: This study aimed to analyze cases of hospitalizations of patients with angioedema associated with the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers during the coronavirus disease 2019 (COVID-19) pandemic. MATERIALS AND METHODS: This study retrospectively analyzed medical records of patients admitted to the Vitebsk Regional Clinical Hospital between May 2020 and December 2020 with isolated (without urticaria) angioedema while receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. In all patients, smears from the naso and oropharynx for COVID-19 were analyzed by polymerase chain reaction. RESULT(S): Fifteen inpatients (9 men and 6 women) aged 44-72 years were admitted because of emergent events, of which 53.6% had isolated angioedema. In two cases, a concomitant diagnosis of mild COVID-19 infection was established with predominant symptoms of angioedema, including edema localized in the face, tongue, sublingual area, and soft palate. All patients had favorable disease outcomes. CONCLUSION(S): Patients with angiotensin-converting enzyme inhibitor-induced angioedema may require hospitalization to monitor upper respiratory tract patency. There were cases of a combination of angiotensin-converting enzyme inhibitor-induced angioedema and mild COVID-19. Issues requiring additional research include the effect of SARS- CoV-2 infection on the levels of bradykinin and its metabolites, the triggering role of COVID-19 in the development of angioedema in patients receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, recommendations for the management of patients with angiotensin-converting enzyme inhibitor-induced angioedema, and a positive result for COVID-19.Copyright © 2020 Pharmarus Print Media All rights reserved.

Impact of COVID-19 Pandemic on Oral Cleft Services in Puerto Rico

OBJECTIVES/GOALS: Evaluate the impact of COVID-19 on oral clefts services including surgical and dental treatments in Puerto Rico. METHODS/STUDY POPULATION: This Observational retrospective cohort study will consider patients 0-21 y/o with CL/P that visited the UPR school of Dental Medicine, Pediatric University Hospital Dr. Antonio Ortiz and ongoing case-control research project Face-Genes. Records to be used are classified as follow: Pandemic (March 15, 2020 to March 15 2022) Pre-pandemic (March 15, 2015 to March 15, 2017) Power analysis (power=0.80 alpha=0.05) will be calculated. Unavailable and incomplete medical records and those that did not attended study clinic during study period will be excluded. Data extraction instrument will be based on previous published study. Descriptive statistics, Chi-square, Odds Ratios at 95% confidence intervals and multiple logistic regression will be estimated. RESULTS/ANTICIPATED RESULTS: We hypothesize that surgical and dental services in Puerto Rico will be adversely impacted because of COVID-19 pandemic. DISCUSSION/SIGNIFICANCE: CL/P are common congenital diseases that require early interdisciplinary attention. Lack of timely care as well as surgery and treatment delays, could be associated with poorer prognosis, increased morbidity and mortality. If there is high risk of dh services during emergency situations, our findings will help to allocate the available resources

The Impact of the Covid-19 Pandemic on Cleft Lip and Palate Service Delivery for New Families in the United Kingdom: Medical and Community Service Provider Perspectives.

OBJECTIVES: Professionals in the United Kingdom providing care to new families affected by cleft lip and/or palate (CL/P) had to adapt to ensure families' needs were met during a time of uncertainty due to Covid-19. The aims of this study were to explore the impacts of the pandemic on CL/P care provision for new families from the perspectives of professionals working in medical and community settings along with any personal impact on professionals and their reflections on the future of CL/P care. DESIGN: Semistructured interviews (n = 27) were completed about experiences from March 2020 to October 2020 with consultant cleft surgeons (n = 15), lead clinical nurse specialists (n = 8), and staff working at the Cleft Lip and Palate Association (n = 4). Transcripts were analyzed using inductive thematic analysis. RESULTS: Three themes were identified: (1) the impact of Covid-19 on the provision of cleft care in the United Kingdom, including working conditions, delays to treatment, and Covid-19 policies; (2) the impact of the pandemic on professionals' mental health, including personal distress and concerns about Covid-19 exposure; and (3) reflections on the future of CL/P care, whereby professionals expressed both hope and concern about the Covid-19 recovery effort. CONCLUSIONS: The ongoing Covid-19 pandemic has impacted CL/P service delivery for new families significantly, warranting recommendations for cohesive psychological support for families in addition to a safe and resourced recovery effort. Support for professionals is also suggested, following existing evidence-based models for providers' needs that address the difficulties of working throughout challenging times.

Clinical and Cytopathological Traits of Herpes Zoster: A Report of Two Cases

Introduction: Varicella zoster virus is a highly infectious alpha-herpesvirus, pathogenic only to humans. The primary infection of varicella zoster virus causes chickenpox, which is contagious and primarily infects children and adolescents in India. Following the primary infection, the virus remains dormant in sensory root ganglia. Activation of the dormant virus in later stages of life causes herpes zoster infection which may vary from subclinical infection to typical zoster, scattered vesicles, zoster sine herpete or disseminated zoster, which depends on the individual's immune status. Case report: In this case series, we present two patients with herpes zoster involving the mandibular branch of the trigeminal nerve. Cytology revealed characteristic features of the infection including nuclear moulding, multinucleated giant cells and ballooning degeneration. Conclusion(s): More recently, patients presenting with herpes zoster have been reported to have sub-clinical Covid-19 infection, suggesting a possibility that herpes zoster might be an indicator for latent Covid-19. Timely detection and treatment of this infection can reduce the risk of post herpetic neuralgia.Copyright © 2022 Sciendo. All rights reserved.

An Unconventional Presentation of Mucormycosis in a 10-Year-Old Child: A Case Report

Since the Coronavirus Disease (COVID-19) pandemic, there have been several unusual presentations of mucormycosis in India, especially amongst immune-competent adults. COVID-19 infection has been found to have profound effects on the patient's immunity and some patients, though asymptomatic for COVID-19, can be infected by mucormycosis and develops dangerous complications. Skin involvement of the orbital, zygomatic and maxillary areas is a common occurrence in extensive cases of rhino-orbital mucormycosis, however, isolated involvement of the alar skin is an extremely rare occurrence in such patients. Paediatric cutaneous mucormycosis is by itself a rare entity, seen majorly in children with history of allogeneic hematopoietic stem cell transplantations, chemotherapeutic treatment, or patients with human immunodeficiency virus infections, herpes and other life-threatening viral infections. Patients receiving long-term steroid therapy are also predisposed to invasive fungal infections. This case was about a 10-year-old boy presented with a black crusted lesion over the nose to the otolaryngology outpatient department. The patient had history of contact with a COVID-19 positive individual. Examination revealed a necrotic patch over the palate and Non Contrast CT Scan of (NCCT) the paranasal sinuses showed pansinusitis. A KOH mount showed fungal elements and the patient underwent emergency debridement of nasal skin with endoscopic sinus and palatal debridement. Injectable liposomal Amphotericin-B was started. Over a period of one month, the patient showed significant clinical improvement. Though rare, sinonasal mucormycosis can present in the form of a cutaneous lesion which is an unconventional symptom. A general awareness amongst healthcare professionals, with a multidisciplinary approach, timely diagnosis and specialist intervention can improve outcomes in this sinister disease.Copyright © 2023 Journal of Clinical and Diagnostic Research. All rights reserved.

Unusual Stroke: Left Ventricular Non-Compaction Causing an Embolic Cerebrovascular Accident

Background Left Ventricular Non-Compaction Cardiomyopathy (LVNC) is a rare genetic, developmental disorder when the left apical chamber of the heart contains bundles or pieces of muscle that extend into the chamber called trabeculations. These trabeculations are a sponge-like network of muscle fibers that typically become compacted to transform heart muscle to become smooth and solid during a normal development process. Those who have LVNC most commonly are asymptomatic. Those who are symptomatic present with syncope, palpitations, dizziness, dyspnea, fatigue and/or unexplained weight gain or swelling. LVNC has also been suggested as a rare cause of embolic stroke, in our patient's case, "due to sluggish blood flow in deep intertrabecular recesses." Case We present a 29 year old African American female, G2P0011, with a history of cleft palate repair, and recent pregnancy complicated by COVID-19 who reported to ED after having a fall the day before, leg weakness and numbness, unable to walk, headache and a left facial droop on day of admission. No family history of SCD or other cardiac disease was noted. On assessment, was found to have NIHSS of 7 with rate lateral gaze palsy, left facial palsy, and decreased strength and sensation of LUE and LLE. TPA was not given due to being outside the therapeutic window. CT head and MRI brain were consistent with acute right MCA stroke. Secondary stroke workup with TTE revealed reduced LVEF 15-20%, loosely arranged myocardium with suspected LVNC and RV apical thrombus. Cardiac MRI showed increased trabeculations consistent with LVNC. Decision-making Currently, there are no ACC/AHA guidelines on anticoagulation in the setting of LVNC. Cardiology and Neurology had an extensive multidisciplinary discussion on the need for anticoagulation specifically with Warfarin. The patient was educated extensively on the need for medical adherence with anticoagulation and guideline directed medical therapy. Conclusion The patient was started on guideline directed medical therapy for cardiomyopathy and was started on Warfarin after bridging from Lovenox. She continued with physical therapy and was noted to have improvement in residual deficits at her outpatient follow up.Copyright © 2023 American College of Cardiology Foundation

An Unusual case of epstein-barr virus hepatitis mistaken for multisystem inflammatory syndrome in children

Case Report: As COVID-19 infections became more common, children began presenting with multisystem inflammatory syndrome (MIS-C). It can be difficult to distinguish rare presentations of common diseases from MIS-C, especially when there has been a close contact with COVID-19. Epstein-Barr virus (EBV) is a universally common infection with 90% of individuals showing serological signs of past infection. Both MIS-C and EBV can present with similar signs and symptoms. Our case aims to remind the reader to keep in mind uncommon presentations of common viral infections which may mimic MIS-C. Case Presentation: A previously healthy 5-year-old girl presented with persistent fevers for 12 days, associated with stomatitis, vomiting, and diarrhea. Physical exam was significant for a moderately ill-appearance, small (<1 cm) left posterior cervical lymphadenopathy, and soft palate and buccal oral ulcers. Initial labs (see Table) revealed leukocytosis with reactive lymphocytes and cholestatic hepatitis with mild coagulopathy. Although she had no respiratory symptoms, CT chest revealed left upper lobe pneumonia. Abdominal ultrasound showed diffuse hepatosplenomegaly, gallbladder wall thickening, and enlarged epigastric lymph nodes. Echocardiogram showed normal systolic function and coronary arteries without dilation. Extensive viral and bacterial nasal swab and serologic testing, including for SARS-CoV-2 antibodies, was negative. On Day 2, her Monospot was positive, along with EBV viral capsid antigen IgM and IgG with the absence of EBV nuclear antigen IgG. In addition, serum PCR was positive for EBV. Management and Outcome: Due to persistent fevers on Day 3 of broad-spectrum antibiotics, coupled with a close contact with active COVID infection, she was treated with the MIS-C protocol of intravenous immunoglobulin G (IVIG), prednisone, and aspirin. Within a day of IVIG, she improved clinically and fever resolved. By discharge on Day 8, her lab values had begun to normalize. Discussion(s): EBV is known to present in children with typical infective mononucleosis symptoms such as fever, sore throat, and lymphadenopathy. However, these can be lacking which makes the diagnosis challenging. Although hepatitis is a common sequalae of EBV, EBV induced pneumonitis and stomatitis are rare, especially in immunocompetent individuals. While our patient improved after treatment with IVIG, suggesting MIS-C, we still attribute her illness to EBV, as IVIG has been shown to provide antiviral and anti-inflammatory benefit in EBV infections. This case highlights the challenge of recognizing and overtreating rare presentations of common viral infections in the face of an emerging disease such as MIS-C. Significant Laboratory Values [Table presented] Copyright © 2023 Southern Society for Clinical Investigation.

Left Ventricular Non-Compaction: An Uncommon Cause of Cardoembolic Stroke

Introduction: Left ventricular non-compaction (LVNC) is a rare, usually congenital or hereditary cardiomyopathy. The formation of deep trabecular recesses increases the likelihood of a thrombus entering the systemic vasculature which may cause cardioembolic stroke. Clinical manifestations of LVNC range from asymptomatic to severe heart failure, thromboembolic events, and sudden death. In adults, individuals with LVNC have a 21 - 38% chance of developing a cardioembolic stroke. Case Presentation: We present a case of a 29-year-old African American female, six weeks postpartum with a history of cleft palate, right sixth nerve palsy, and recent Covid-19 infection who developed stroke-like symptoms of left side numbness and weakness, left side facial droop and slurred speech upon awakening. On initial examination, the patient displayed 4/5 strength and decreased sensation to pinprick in left upper and lower extremities as well as left lower facial palsy and dysarthria. CT head without contrast revealed a large infarct in the right middle cerebral artery (MCA) territory. A brain MRI confirmed the right MCA infarct but did not reveal acute infarct in other vascular territory. CTA head/neck reported right MCA proximal M2 segment occlusion. During admission, stroke work-up included a normal EKG. A transthoracic echocardiography (TTE) with bubble study was obtained which reported no patent foramen ovale but with severely reduced systolic function with a LVEF estimated 15-20%;questionable right ventricle apical thrombus was also suspected. Cardiology was consulted for acute systolic heart failure with plans to initiate goal directed medical therapy. A cardiac MRI was recommended which revealed left ventricle increased trabeculations meeting MRI criteria for LVNC, but no cardiac thrombus was detected. Patient was started on warfarin with enoxaparin bridging for secondary stroke prevention. Discussion(s): Given our case's young age of onset of stroke and the history of postpartum and recent COVID-19 infection, cardioembolic stroke due to other more common etiologies such as hypercoagulable disorders, postpartum cardiomyopathy or COVID-19 associated cardiomyopathy were initially suspected based on the initial TTE findings. Subsequent cardiac MRI revealed LVNC as an unusual cause of her cardioembolic stroke. This case illustrates the importance of thoroughly investigating the potential managementchanging causes of stroke, including congenital structural cardiac abnormalities, in patients with young age of onset.

Diagnostic Tools in COVID-19-Associated Mucormycosis: Do We Need 3-dimensional Computed Tomography

Introduction: Early detection of COVID-19-associated mucormycosis (CAM) is critical for accurate staging and optimal treatment. Three-dimensional computed tomography (3D CT) reconstruction of the face has recently come up as a newer diagnostic tool in CAM. Method(s): This clinical study was done to evaluate the efficacy of 3D CT in diagnosing and managing CAM. We compared 3D CT reconstruction with conventional 2D CT. One hundred twenty-three confirmed cases of mucor were subjected to 3D CT reconstruction in addition to contrastenhanced magnetic resonance imaging after comprehensive clinical workup. The involvement of maxillary walls, alveolus, palate, orbital floor, zygomatic process, and other facial skeleton were noted. The plan of management was decided after assessing the extent in 3D CT. Result(s): Anterior maxillary wall was found to be the commonly involved (9.7%). Involvement of the lateral maxillary wall was noted in 8.1% of subjects. Sixty-seven subjects underwent endoscopic endonasal debridement, 19 underwent total maxillectomy, 3 had infrastructure maxillectomy, 8 had orbital exenteration, and 12 had combined endoscopic and open surgeries. In 21 patients (17%), open surgery was done based on additional 3D CT findings at the first instance and revision surgeries were avoided. Conclusion(s): 3D CT face was found to be superior to conventional CT in diagnosing the extent of disease and plays an important role in preoperative surgical planning of CAM. Minor cortex erosions are not picked up by conventional CT;it also does not show finer details and leaves the surgeon imagining the disease extent. 3D CT decreases delay in diagnosis, facilitates the surgical plan, and reduces the need for multiple surgeries. It is a valuable tool in the assessment of revision cases and follow-up.

Sonographic Phenotyping of the Upper Airway in OSA With Backscattered Imaging Analysis by Machine Learning

Introduction: Anatomic assessment of the upper airway remains important in directing and monitoring of care for patients with obstructive sleep apnea (OSA). Nasopharyngoscopy is routine in clinical practice, but it can be invasive and potentially less attractive in the post-COVID-19 care setting. It also only allows subjective assessment. Ultrasound imaging of the upper airway with backscattered imaging analyzed via machine learning algorithm is investigated as a potential alternative. Method(s): Sixty-three subjects (14 female) with a mean age of 39.4 (12.6) years, body mass index (BMI) of 26.4 (4.6) kg/m2, and apnea-hypopnea index (AHI) of 19.0 (16.1) were consented from Stanford sleep surgery (July 2020 to May 2021). A standardized ultrasound protocol was used to image the soft palate, oropharynx, tongue base, and epiglottis. Via ultrasound device cleared by US Food and Drug Administation, backscattered ultrasound imaging (BUI) of the upper airway was performed and analyzed with machinelearning algorithms. Combined with B-mode measurements of airway muscular cross-sections, a logistic regression model was built to correlate with OSA severity. Result(s): The BUI of subjects with mild OSA was different from moderate-severe (AHI>=15) OSA at the soft palate (P=.0007). The axial-to-lateral ratio of upper airway length was reduced in the lower soft palate of the moderate-severe group (P=.0207). The logistic regression model with BUI, axial-to-lateral ratio at the soft palate, and BMI showed an area under the receiver-operating characteristic curve of 0.84 (95% CI, 0.726-0.920) in moderate-severe OSA. Conclusion(s): A noninvasive yet replicable technique to visualize and phenotype the upper airway is critical in the management of patients with sleep-disordered breathing. Sonographic BUI combined with B-mode airway measurements analyzed by machine learning show promise in characterizing the upper airway in patients with moderate-severe OSA.

COVID-Associated Mucormycosis in Case of Fibrous Dysplasia of Maxilla: Freeing 2 Birds With 1 Key

Introduction: India is one of the countries most affected by COVID-19. COVID-19-associated mucormycosis (CAM) has added to the woes of the already devastating effects of the virus. About 97.6% of cases in India presented with rhino-orbito-cerebral disease. Fibrous dysplasia (FD) is characterized by abnormal mixtures of fibrous and osseous elements leading to bony deformities and pathological fractures. Monostotic and polyostotic varieties have been described, with the latter being more common in children. The monostotic type of FD accounts for about 70% to 80% of FD, affecting the second and third decade. Method(s): We present a case of 44-year-old man with fibrous dysplasia of left maxilla with CAM, an angioinvasive fungal disease associated with high morbidity and mortality. As India and the entire world is struck by the COVID-19 pandemic, the use of corticosteroids has proven somewhat helpful in managing severe COVID infection. Evidence shows it has also led to CAM. Our patient was treated with radical surgical treatment of lesion with gross removal of all necrotic tissues from the sinuses along with antifungal treatment with amphotericin B. FD is a benign disorder characterized by replacement of normal bone with cellular fibrous connective tissue. Result(s): Our case presented with CAM of maxilla with palatal involvement requiring urgent surgical intervention and antifungal therapy. It incidentally happened to be a case of FD. Maxillectomy took care of the patient's FD as well. Conclusion(s): FD is a disorder characterized by dystrophy and bony metaplasia, and treatment depends on the zone of involvement. Early diagnosis and surgical intervention, with good antifungal therapy with strict glycemic control, are critical features to prevent its onslaught. Sometimes treatment of one condition can cure the others as well.

Fabrication of single piece definitive obturator for post surgical maxillectomy defect during covid-19 pandemic-A Literature review with Clinical case report

Background: Impacts of primary oncology surgical procedure can impede restoration objectives. Restoring oral function, comfort and aesthetics is a challenge due to limitations in the restorative treatment options. Methodology: Literature review on the responsibilities, role of maxillofacial prosthodontist, materails and retentive aids used for prosthesis, classification of maxillofacial prostheses, recent advancements in MFP and Workflow for the fabrication of obturator prostheses in the COVID-19 pandemic scenario. Case report on the fabrication of Holllow bulb definitive obturator during pandemic crisis. A 47 years old male patient reported for post-surgical evaluation in maxillary posterior region of oral cavity. The patient had partial maxillectomysurgical procedure of squamous cell carcinoma in the palate 5 years back. To replace the gap created, the patient was using interim obturator. He had facial asymmetry and collapse. Prosthodontic rehabilitation with one piece closed hollow bulb obturator was planned & subsequently fabricated for the patient. For our case considering the feasibility & ease of manipulation, heat activated acrylic resin was used for this particular patient for rehabilitation. The method described is easy, simple, time saving & economical. Bulb portion was hollow & made of heat cure resin, so weight was less & less chances of tissue irritation. Results: With the Covid-19 infection protocol measures taken definitive obturator was given to the maxillectomy patient to restore aesthetics, function and comfort as well. After insertion of prostheses mastication, deglutition and phonetics were improved. Breathing problems were resolved and aesthetics was improved. Conclusion: A simplified technical approach for the treatment of a patient with palatal defect of and other supportive structure has been presented in Covid-19 situation following the described infection prevention protocols. The technique presented offers a method of obtaining a detailed impression of the defect and promptly provides the patient with a light weight, easyto-use and flexible tissue-tolerant obturator.

CLINICAL STUDY OF SURGE OF MUCORMYCOSIS IN COVID-19 PANDEMIC: A TERTIARY CARE CENTER STUDY

Background: Mucormycosis is a serious and rare fungal infection that mostly affects the immunocompromised. The symptoms depend on the body part affected or the site of infection. By infecting the nose, sinuses, eye, lungs, and brain, it produces a runny nose, one-sided facial swelling and pain, headache, fever, poor vision, bulging or displacement of the eye (proptosis), and tissue death. Various ailments may cause problems with the skin, stomach and intestines, and lungs. The objective of this research is to assess the prevalence, aetiology, treatment, and prognosis of mucormycosis in post-covid patients at our covid-specific tertiary care hospital. Materials and Methods: A prospective cross-sectional study was conducted on 50 patients admitted to the GGH/Government Medical College's Nizamabad covid department between May 2021 and August 2021 and diagnosed with mucormycosis. Result: The age groups most often affected by mucormycosis ranged from middle-aged to elderly. As a consequence of the ongoing covid pandemic outbreak, few of the affected population, who were mainly diabetic and had a range of hospital presentations, were discovered to have mucormycosis. Covid infection had significant impact on endocrine system as seen by uncontrolled blood glucose levels. The important components of efficient therapy of this condition include early detection, medical care, surgical debridement, proper antifungal medication, and treatment of associated disorders such as diabetes mellitus. Conclusion: Mucormycosis is a rapidly progressing sickness that has been demonstrated to be incurable in late presentation and can cause death;however, early detection and therapy may minimise mortality.

Anesthetic Approach and Perioperative Complications in Cleft Lip/Palate Surgery: A Single Center Retrospective Study

Objective: The objective of this study was to determine factors that may affect anesthesia and surgical complications, difficult airway, and the need for intensive care unit (ICU) care in cleft lip and cleft palate (CLCP) surgeries. Materials and Methods: The study was a retrospective review of the records of 617 patients who underwent CLCP surgery between 2015–2019. Results: The number of anesthesia complications was higher in patients with difficult mask ventilation. Surgical complications were more common in patients >1 year of age. Isolated cleft palate (CP) surgery;presence of a concomitant disease, syndrome, or micrognathia;age >1 year;and the CP subtype were associated with a higher rate of difficult intubation. Isolated cleft palate, concomitant disease, syndrome, micrognathia, difficult intubation, difficult mask ventilation, and anesthesia complications were associated with ICU admission. Conclusion: The CP subtype was associated with a higher rate of difficult intubation and ICU hospitalization even in patients who were nonsyndromic and/or >1 year of age. Therefore, special attention should be paid to the anesthesia and surgical management of these patients.

Sleep and alimentation: actions for improving quality of life in times of COVID 19

Introduction: Sleep is characterized as a condition of physical and mental rest, in which the person ignores everything going on around him. There is a scientifically proven association between sleep deprivation and unhealthy eating habits, increasing cases of emotional and uncontrolled eating leading to malnutrition. In addition, a bad night's sleep has been associated with worsening mental health, especially in times of pandemic. Objective: In light of the above, this study aimed to report the experience and stimulate reflection about the results of a poll shared on the social network Instagram with the objective of analyzing the quality of sleep of students at a public higher education institution during the COVID-19 Pandemic. Methods: This is an experience report of the extension group “Sleep and Food in times of Pandemic”, composed of students of nursing, nutrition, medicine and mathematics of a public institution of higher education. The group, through its profile on the social network Instagram, shared a sleep satisfaction scale, where users reported in posts according to the condition of their sleep on a scale between good and bad. The scale was made available publicly and online, so the answers were freely accessible to everyone who followed the group's profile. Results: The project had a large significant reach of participants, since the present was observed through the social media of we can mention Instagram e Facebook, that is, an average of 600 posts observed, of these, 34.5% of students reported having a good night's sleep during the pandemic, while 65.5% responded by pointing out a bad night's sleep. Sleep deprivation is inversely related to the regulation of the circadian cycle, is associated with neuroendocrine and metabolic functions, such as reduced leptin and increased ghrelin, increasing appetite and food intake.In parallel to this, individuals in this stressful situation tend to consume foods that are pleasing to the palate, which usually contain higher amounts of sugar and/or fat, because they serve as comfort for the stress they are going through, but may contribute to the risk of developing obesity, insulin resistance, and cardiovascular disease. Conclusion: Some protective factors can help in this change, such as maintaining a daily routine, practicing physical activity, following a dietary pattern and taking care of sleep hygiene. Finally, we emphasize the need for more studies with a more rigid methodological content.

Atypical Presentation of Lance Adams Syndrome in the setting of Clonazepam overdose and SARS-CoV-2 pneumonia

Objective: To report an atypical presentation of Lance-Adams Syndrome presenting from severe respiratory depression rather than cardiac arrest and to highlight the importance of distinguishing it from post hypoxic myoclonic variants. Background: Clinicians often face difficulty distinguishing Lance-Adams Syndrome (LAS) from Myoclonic Status Epilepticus (MSE). Similarities between the two conditions frequently result in confusion when diagnosing, managing and prognosticating for post-hypoxic myoclonus patients. Design/Methods: A 23-year-old male with a history pertinent for Hemophilia B, depression, opiate and alcohol abuse and chronic pain was found down in his home next to an empty bottle of clonazepam. He was hypoxic with oxygen saturation in the 40s and intubated in the field. Upon arrival to the Emergency room, neurological examination revealed intact corneal reflexes but no gag reflex, cough, or purposeful movements of the extremities. The patient exhibited stimulus induced myoclonic jerking which lasted >30 minutes despite being loaded on valproic acid and levetiracetam. Jerking subsequently ceased with propofol drip. Chest X-ray confirmed interstitial opacities and tested positive for SARS-CoV-2. On attempting to wean sedation, patient exhibited full-body myoclonus including face and palate with inability to follow commands and lack of spontaneous movements. As the EEG showed BIPEDS greater than 2.5 HZ, we decided to burst suppress him and treat with targeted temperature management. After 10 days, the patient was successfully weaned from sedation and extubated, but remained on multiple anti-seizure medications. Results: Patient responded well despite his diffuse cerebral anoxic injury. He regained the ability to follow commands upon discharge but had residual moderate expressive aphasia and post-hypoxic action-induced myoclonus, consistent with LAS. Conclusions: The atypical presentation of this case emphasizes the importance of distinguishing LAS from MSE to guide neurologists to aggressively treat LAS to improve outcome, particularly since MSE historically results with a 90-100% mortality rate.

Management of Post COVID Mucormycosis -Maxillectomy

Background:Mucormycosis has been increasingly described in patients with covid 19 2nd wave (delta variant) which is a highly contagious disease caused by SARS-COV-2 is the leading cause of global pandemic. AIM AND OBJECTIVES: To evaluate etiology, indications, management options and complications in patients managed with endoscopic and external maxillectomy after mucormycosis, to evaluate the incidence and distribution of cases who had extensive mucormycosis and to evaluate the outcome of the management options. Materials and Methods: This is a prospective study done in 30 cases at a tertiary care centre.All the patients were subjected to detailed history taking, clinical examination, endoscopic, radiological, pathological, microbiological investigations after taking informed consent. Patients with age group(30yrs -70yrs) who presented with ROM with extensive maxillary sinus involvement and destruction of different walls of the maxillary sinus were managed with different types of maxillectomies. Results: In this study, 30 cases of post covid rhinoorbital mucormycosis who presented to our hospital were studied, among male 24(80%) & females6 (20%).12 patients (40%) were in 5th to 6th decade and 9 patients (30%) in 4th to 5th decade.Main presenting features were unilateral cheek pain, cheek swelling, nasal obstruction, loosening of teeth, tooth ache, cheek numbness, headache, periorbital edema, visual disturbances being present in 95% of the patients.5% presented with epistaxis, ptosis, diplopia alone.90% patients were known case of diabetes milletus,10% are denovo diabetes.All the patients were subjected to routine blood investigations, microbiological, radiologicalinvestigations.(CT, MRI contrast- PNS, Orbit & Brain).Most commonly seen in males 80%. 1 patient had to undergo orbital exenteration,3 patients underwent palatal resection. Conclusion: Debridement of sinuses is necessary in all cases of mucormycosis so that the fungal reservoir could be removed and the antifungal therapy can reach the viable areas. Therefore the management of mucormycosis is individualised to each patient based on the extension of the disease and overall general conditon of the patient.