As the virus sowed, the fungus reaped! A comparative analysis of the clinico-epidemiological characteristics of rhino-orbital mucormycosis before and during COVID-19 pandemic.

BACKGROUND: The sudden surge of mucormycosis cases which happened during the second wave of COVID-19 pandemic was a significant public health problem in India. OBJECTIVES: The aim of this study was to analyse the clinico-epidemicological characteristics of the mucormycosis cases to determine the changes that had occurred due to COVID-19 pandemic. METHODOLOGY: A retrospective cross-sectional study was conducted at the Department of Otolaryngology Head and Neck Surgery, PGIMER, Chandigarh, India. Patients diagnosed with rhino-orbital mucormycosis were categorised into the following groups: Pre-pandemic(May 2019 to April 2020), Pandemic Pre-epidemic (May 2020 to April 2021) and Epidemic (1 May 2021 to 12 July 2021). The epidemiological, clinical and surgical data of all the patients were retrieved from the hospital records and analysed. RESULTS: The epidemic period had 370 cases, compared with 65 during pandemic period and 42 in the pre-pandemic period. Diabetes mellitus was seen in 87% of cases during epidemic period, 92.9% in the pre-pandemic period and 90.8% in the pre-pandemic pre-epidemic period. The proportion of patients suffering from vision loss, restricted extra-ocular movements, palatal ulcer and nasal obstruction was higher in the pre-epidemic groups, and the difference was significant (p, <.01). There was no history of oxygen use in 85.9% of patients and no steroid use in 76.5%. The death rates were the lowest during epidemic (10%). CONCLUSION: COVID-19 has caused a statistically significant increase in the number of mucormycosis infections. The mortality and morbidity which showed an increase during the first wave of COVID-19 decreased significantly during the epidemic period.

Role of Oncofetal Protein CR-1 as a Potential Tumor Marker for Oral Squamous Cell Carcinoma.

Cripto-1 (CR-1) is an oncofetal protein with its role as a key factor in early process of carcinoma has been evaluated in cases of various cancers. However, very few studies have reported its role in oral cancer, which is the sixth most common cancer around the world, particularly with high prevalence in developing countries. Oral squamous cell carcinoma (OSCC) is the most predominant (90%) of all the histological types of oral cancer. Late detection, associated with increased morbidity and mortality, is mainly attributed to non-availability of a suitable biomarker for the disease. In the present pilot study, we have evaluated the role of soluble CR-1, in serum as a potential tumor marker for OSCC. CR-1 was estimated using sandwich ELISA in serum samples of 50 biopsy proven OSCC patients (pre and post treatment) along with age and gender matched healthy controls. Immunohistochemistry was also done in corresponding tumor tissue sections to check the expression of CR-1. Pre-treatment CR-1 was found to be 2.25-fold higher in serum of OSCC patients as compared to control (p < 0.0001***), which was reduced to 1.6 folds post treatment (p = 0.0006***). CR-1 levels were comparatively higher in early stage of disease. Upon IHC 80% of the cases were found to be positive for CR-1. This study provides evidence that serum levels of CR-1 are elevated in patients of Oral Squamous Cell Carcinoma, which decrease post treatment. Also, the association of expression of protein with tumor progression predicts CR-1 as a molecule that can be further evaluated as a potential tumor maker in OSCC.

Endoscopic management of congenital nasal meningoencephaloceles: a short series of 15 paediatric cases.

PURPOSE: To retrospectively analyse surgical management of clinico-radiologically proven nasal meningoencephalocele amongst children and results of repair with single-layer septo-mucosal flap at a tertiary skull base surgery centre in north India. METHODS: Fifteen children with clinic-radiological nasal meningoencephaloceles with or without CSF rhinorrhoea were included. Radiological scans included CT scans and MRI scans for all cases to delineate soft tissue and bony architecture. All children underwent endoscopic excision of encephaloceles and repair of the skull base defect. RESULTS: The authors were successful in fourteen cases. Successful cases included 4 children less than 6 months of age who underwent single-layer rotated septo-mucosal flaps, thereby avoiding donor site morbidity. CONCLUSION: As endoscopic excision of nasal encephalocele is an established management approach, the authors take the concept of minimally invasive surgery a step further by successfully managing these lesions with single-layer repair. Vascularized septo-mucosal flap seems to be the only determining factor for a successful repair for congenital meningoencephalocele. However, a prospective study comprising a larger subset of patients would substantiate the assumption.

Management of CVJ tuberculosis: the changing paradigm.

BACKGROUND: The literature seems fractured for the management of craniovertebral junction (CVJ)-tuberculosis (TB). Presently, non-surgical management has been in vogue for neurologically intact patients. On the contrary, severely disabled cases of CVJ-TB continue to attract discussion, tilted towards surgical intervention. We present our experience with the non-surgical management of CVJ-TB tailored to their neurological status. METHODS: Authors managed 37 cases (2004-2019; age 1-57 years, mean 36 years) of CVJ-TB, of which eighteen (18/37, 48.6%) were severely disabled (Nurick grade ≥ 3) with a mean follow-up of 84 months (48-192 months). Irrespective of the clinical status and radiological findings, all patients were managed on medical management only. Needle aspiration established pathology in 23 (62.2%) cases, while 9 (24.3%) cases required drainage of an abscess. All patients received 18 months of anti-tubercular therapy (ATT). In patients with Nurick grade ≥ 3 and documented AAD, we applied halo vest for 12 months to achieve cervical immobilization. Only hard cervical collar for 3 months was prescribed in patients with no documented AAD. RESULTS: All minimally disabled cases (Nurick grade ≤ 2, n = 19) responded favorably (n = 18) to ATT, except for an infant, who succumbed to irreversible hypoxic brain damage due to the obstructed aero-digestive gateway. Of the severely disabled cases (Nurick grade ≥ 3, n = 18), 16 cases had favorable outcomes with only external orthosis (12) and 18-month ATT. One patient succumbed to multiple cerebral infarcts, while one required realignment surgery at CVJ due to fusion in malaligned position. CONCLUSION: The authors conclude that the disability grading of CVJ-TB is pertinent only for assessing the functional disability of patients at presentation, with minimal relevance in deciding its management strategy. Irrespective of neurological disability, almost all patients respond favorably to external immobilization and ATT.

Multiple intradural spinal metastases of esthesioneuroblastoma: A case report.

Spinal metastases from esthesioneuroblastoma (ENB) might have variable presentations. Discrete lesions, even when multiple, warrant radical excision, followed by radiotherapy. The authors present a case of anterior skull base ENB, metastasizing to spine at muliple levels. Clinical and radiological pictures are described with intraoperative findings.

Ochroconis humicola coexisting with esthesioneuroblastoma: an incidental coloniser or allergen?

Ochroconis humicola, a fish pathogen, is rarely reported to cause disease in human. We report its first isolation from nasal tissue of a human immunodeficiency virus-positive young female patient. Histopathologically, the nasal mass was diagnosed as esthesioneuroblastoma. She presented with right-sided nasal obstruction and bleeding for two and half months. Computed tomography scan showed the nasal mass filling the whole right nasal cavity, maxillary, ethmoid and sphenoid sinuses. The direct microscopy of the nasal tissue and mucin demonstrated the presence of septate hyphae. On culture, O. humicola was isolated from the same tissue and the fungus was identified by morphologic, physiologic and molecular data including sequencing of ITS and 28S rDNA regions. No antifungal was prescribed, and the whole mass was resected out by endoscopic surgery. The patient was treated further by radical radiotherapy. After 1 year of follow-up, patient is stable with no recurrence of tumour. The role of this fungus was not clear, as it may be bystander or producing allergic fungal rhinosinusitis.

Primary osteosarcoma of clivus: a short report.

Next to multiple myeloma, osteosarcoma is the commonest primary malignant neoplasm of skeletal system. These are aggressive tumours, composed of spindle cells producing osteoid and rarely occur in calvaria. The authors report a 55-year-male harbouring clival osteosarcoma, his clinical presentation, radiological findings, management and outcome.

Unveiling the Allergy-Meniere Connection: Exploring the Impact of Allergen Positivity on Meniere's Disease Severity.

Meniere's Disease is a rare ear disorder that can cause severe morbidity to the patient and has no definitive treatment to date. Endolymphatic hydrops is the critical event. Though symptomatology is well understood, the exact etiology of Endolymphatic hydrops attack is still unclear. Twenty-five consecutive patients of Meniere's Disease diagnosed in the Vertigo clinic aged 12 to 70 years were included. Their allergic status was evaluated using a skin prick test. Allergic and non-allergic patients were then identified. Comparison between the two groups was made to identify the effect of allergy on the severity of symptoms using vertigo scales, Functional level scale, Dizziness handicap index, and Pure tone average staging. The prevalence of allergy among Meniere's Disease patients was 56%. The most common allergen found in our study was tyrophagus(n = 8). Polysensitization was more common(n = 12). Airborne allergens were more common than food allergens. There was no significant relationship between the severity scales and the allergen positivity status (p > 0.05). The prevalence of allergy is more among patients with Meniere's Disease. The Endolymphatic sac is allergy prone. The occurrence of endolymphatic hydrops may be due to a cross-reaction of allergen-induced IgE antibodies to self-antigen. Management of the specific allergen may help decrease symptomatology in these patients. Allergen-specific therapies have a promising role in the treatment of allergic conditions and provide a long-term symptom-free period in affected individuals. This can be applied in patients with Meniere's Disease having associated allergic features based on their skin prick test results.

Incidental Detection of Lipomatous Hypertrophy of the Interventricular Septum on FDG PET/CT.

ABSTRACT: Cardiac lipomatous hypertrophy is a rare benign condition almost exclusively involving the interatrial septum. Interventricular septum involvement is seldom noted, with only a few documented case reports demonstrating the finding on various modalities such as ECHO, CT, and MRI. FDG PET can be a surrogate marker for lipomatous hypertrophy of the interventricular septum. Here, we describe a case of incidentally detected lipomatous hypertrophy of the interventricular septum on FDG PET/CT in a patient with squamous cell carcinoma of the oropharynx.

Evaluation of ultrasound-guided suprazygomatic maxillary nerve block in functional endoscopic sinus surgery for postoperative pain relief: A randomised controlled trial.

Background and Aims: Postoperative pain can impede functional recovery and delay hospital discharge after functional endoscopic sinus surgery (FESS). The study aimed to assess the efficacy of ultrasound (USG)-guided suprazygomatic maxillary nerve block (SZMNB) for postoperative pain in FESS. Methods: Forty-eight adult patients between 18 and 65 years of age with American Society of Anesthesiologists physical status I and II and scheduled to undergo FESS were enroled in this randomised controlled study. Patients were randomly allocated to either receive USG-guided SZMNB with general anaesthesia (n = 24) or general anaesthesia alone (n = 24). The numerical rating scale (NRS) pain score in the immediate postoperative period was recorded as the primary outcome. A total of 24 h postoperative rescue analgesic consumption, surgeon satisfaction score, postoperative haemodynamics, and postoperative complications were noted as secondary outcomes. Results: The median (interquartile range) of the NRS pain score in the immediate postoperative period was 0 (0-0.25)[95% confidence interval (CI): 0, 0.08] in the block group compared to 2 (1.75-3) [95% CI: 1.60, 2.40] in the control group, P < 0.001]. Pain scores were significantly reduced at all time intervals till 24 h after surgery (P < 0.001). None of the patients required rescue analgesia in the block group. In contrast, eight patients required diclofenac 75 mg intravenous as rescue analgesia within 1 h of surgery and ten patients within 1-6 h of surgery in the control group. Other secondary outcomes were comparable between groups (P > 0.05). Conclusion: The USG-guided SZMNB provides excellent postoperative analgesia for patients undergoing FESS without significant side effects.

Endoscopic repair of CSF rhinorrhea: necessity of fibrin glue.

OBJECTIVE: The aim of this study is to compare the efficacy of cerebrospinal fluid (CSF) repair with and without fibrin glue in pediatric patients with CSF rhinorrhea treated endoscopically. MATERIALS AND METHODS: This was a retrospective study carried out in the Departments of Otolaryngology and Neurosurgery at a tertiary care center between December 2005 and July 2010. RESULTS: The 27 patients with CSF rhinorrhea included in the study were divided into Group A: 13 patients who underwent endoscopic endonasal CSF repair using fibrin glue (Tisseel, Baxter, Vienna, Austria) by an endoscopic rhinologist and Group B: 14 patients who underwent endonasal CSF repair without fibrin glue. There was no statistically significant difference in endoscopic CSF repairs with or without fibrin glue (P = 0.48) in all the variables studied. CSF repair without fibrin glue appeared more cost saving as compared to repair with glue. CONCLUSION: CSF repairs with and without fibrin glue are equally effective and CSF repair without fibrin is costs saving.

Primary hydatid cyst presenting as a mass in the supraclavicular region: an unusual case report and literature review.

Hydatid disease, also known as echinococcosis or hydatidosis, is an infectious disease caused by the cestode Echinococcus. Echinococcus granulosus is the most common Echinococcus species affecting human beings. It may affect any organ and tissue in the body, in particular the liver and lung. Musculoskeletal or soft tissue hydatidosis accounts for about 0.5%-5% of all echinococcal infections in endemic areas, and is almost always secondary to the hepatic or pulmonary disease. Even in regions where echinococcosis is endemic, hydatidosis of cervicofacial region is extremely rare. Herein, we present an exceptionally rare case with an unusual localization of primary hydatid cyst in the right supraclavicular region of the neck without involvement of the lungs or pleura.

Prevelance of Common Aeroallergens in Allergic Rhinitis and its Correlation with Bronchial Asthma: A Study on 798 Patients by Skin Prick Test.

Allergic rhinitis affects 30% of the Indian population (Dey et al. in Int Arch Allergy Immunol 178:60-65, 2019). Patients can be sensitive to single or multiple allergens. Polysensitization is more common (Bousquet et al. in Ann Epidemiol 20:797-803, 2010; Arbes et al. in J Allergy Clin Immunol 116:377-383, 2005). Sensitization to multiple allergens may have a role in the severity and the association of Asthma in such patients. A total of 798 patients with allergic rhinitis (SFAR ≥ 7) were included. Disease severity and associated symptoms were evaluated using questionnaire. Each patient underwent a Skin prick test with an allergen panel of 35 allergens each (Annesi-Maesano et al. in Allergy 57:107-114, 2002) and the results were evaluated to study the association of asthma and severity of Allergic rhinitis. Data consisting of 389 (48.7%) males and 409 (51.3%) females were assessed. A total of 82.2% of the study population of symptomatic patients were sensitized to at least one of the allergens. Seventy patients (8.78%) had associated asthma. Forty-four patients were polysensitized and fifteen were mono sensitized. Among polysensitized patients, 36 patients had sensitization to at least 6 different allergens. Dermatophagoides pteronyssinus was the most common allergen among asthma patients. This study provides a thorough knowledge of locally prevalent aeroallergens which is essential for the prompt diagnosis and treatment of allergic patients. Skin prick test can be a non-invasive vital tool in analyzing patterns of allergen exposure, the prevalence of allergen, sensitizing potential of different allergens in that specific geographic area.

Sinonasal and Olfactory Quality of Life in Endoscopic Pituitary Surgery and Time Interval to Olfactory Recovery: A Comparative Prospective Study.

Background and Objective: Superior turbinate manipulation is often required in cases of narrow cavities and expanded endonasal approaches with concern for olfaction. The objective of the study was to compare the pre- and postoperative olfactory function in patients undergoing endoscopic endonasal transsphenoidal pituitary excision with and without superior turbinectomy, using the Pocket Smell Identification Test and the quality of life (QOL) and Sinonasal Outcome Test-22 (SNOT-22) scores, irrespective of the extension (Knosp grading) of pituitary tumors. We also aimed to identify olfactory neurons in the excised superior turbinate with immunohistochemical (IHC) stains and correlate them with clinical findings. Materials and Methods: The study was a prospective, randomized study performed in a tertiary center. Two groups A and B, with superior turbinate preserved and resected, respectively, during endoscopic pituitary resection, were compared using pre- and postoperative Pocket Smell Identification Test and QOL and SNOT-22 scores. The superior turbinate was subjected to IHC staining to identify the presence of olfactory neurons in patients with tumors of pituitary gland requiring endoscopic trans-sphenoid resection. Results: Fifty patients with sellar tumors were enrolled. The mean age of patients in this study was 46.15 years. The minimum age was 18 years and the maximum was 75 years. Of the 50 patients in the study, 18 were female and 32 were male. Eleven patients had more than one presenting complaint. Loss of vision was the commonest and altered sensorium was the rarest symptom. Conclusion: Superior turbinectomy is a viable option to gain wider access to sella without affecting the sinonasal function, quality of life, and olfaction. There was doubtful presence of olfactory neurons in superior turbinate. The extent of tumor resection and postoperative complications were unaffected and statistically nonsignificant in both the groups.

Development of Phonemically Balanced Passage, Oral Passage, and Nasal Passage in the Punjabi Language.

The primary aim of the study was to develop phonemically balanced passage, Oral passage and Nasal passage in Punjabi language. Development of the passage: The words in the passage were chosen to represent the way sounds are distributed in spoken Punjabi language, and the relative phonemic distribution of each word inside each paragraph matched how frequently each sound occurs in Punjabi. The paragraph was constructed using words that were rated as extremely familiar and familiar. The developed passages were given to five speech-language pathologists for the purpose of content validation. 100 people with normal hearing between the ages of 18 and 25 were enrolled in the study (50 female and 50 male). Each subject's nasalence was measured using a Nasometer. The individuals were given passages written in Punjabi to read, and their nasalence scores for each text were recorded. The nasalance mean for Punjabi phonemically balanced passage was 36.41 ± 4.61% and 38.57 ± 4.22% in male and female subjects. The Punjabi oral passage mean were 27.36 ± 4.14% and 28.46 ± 4.01% in male and female subjects. The means for Punjabi nasal passage were 46.15 ± 4.09% in male subjects and 47.04 ± 4.91% in the female subjects. The Intraclass correlation coefficient for Female and male subjects for the Punjabi Phonemically balanced passage, Punjabi oral passage, Punjabi nasal passage were 0.904, 0.945; 0.807, 0.909, and 0.956, 0.913 respectively. The developed passages have good test retest reliability and their normative scores can be used for assessment of different resonance disorders.

Allergic fungal sinusitis: innocence under suspicion.

The objective of this investigation was to explore the possibility of treating patients harboring invasive intracranial aspergillosis (InIA) at an early stage. Nineteen patients (age range 18-42 years) from a total of 114 cases of InIA seen from January 1999- December 2009 were included in this investigation. These individuals, all of whom had a past history of treated allergic fungal sinusitis (AFS) were evaluated as to their immune status, clinical presentations, time-intervals and radiological findings. Past records of seven patients indicated skull base erosion and extension of the paranasal (PNS) masses into intracranial cavity, but none had neurological deficits or symptoms suggestive of raised intracranial pressure. All 19 patients had undergone endoscopic clearance of PNS during their first presentations. Both AFS and InIA were found simultaneously in seven patients, while the time-interval between the two forms was as long as 10 years for two patients. Overall mortality was (8/19; 42%) with all deaths attributable to fungal meningo-encephalitis. As InIA carries a high mortality rate, it seems prudent to evaluate and treat these patients early in the course of their illness. The appearance of the invasive form of the disease in patients with a past history of AFS is not uncommon. The allergic form of disease may not be considered as a separate entity from InIA as both the pathologies may exist in same patient.

Traumatic chiasmal syndrome.

A case of closed head trauma, harbouring bitemporal hemianopsia is presented. The MRI evaluation describes chiasmal contusion as the cause behind visual deficits. Chiasmal injury may occur even in the absence bony chip impingement and features of hypo-pituitarism. Such a situation warrants MRI evaluation of optic pathways.

Surgical Field Quality in Trans-Nasal Endoscopic Surgeries Using Lignocaine Infusion and Dexmedetomidine Infusion. A Prospective Randomized Control Study.

Trans-nasal endoscopic surgery (TNES) is a helpful diagnostic and therapeutic modality in otorhinolaryngology surgeries and requires controlled hypotension for better visualization of the surgical field. Recent literature shows evidence of intravenous Lignocaine infusion to produce the controlled hypotension. The study aims to assess and compare the effects of Lignocaine (LIG) and Dexmedetomidine (DEX) infusion with respect to surgical field quality. 101 Consenting adult patients undergoing elective TNES were double-blinded, randomly allocated in one of the two groups and received either DEX infusion of 0.5ug/kg/hr (n = 51) or LIG infusion of 1.5 mg/kg/h (n = 50) after a loading dose. Surgical field score (SVF) as the primary outcome and secondary outcomes such as variations in hemodynamic parameters, the requirement for rescue agents and total blood loss were recorded. Both the groups were comparable with respect to patient demographics, total duration of anesthesia and surgery. SVF scores were significantly better in the LIG group during the first 105 min of the surgery (p < 0.05). In response to intubation, hemodynamic parameters were lower in LIG group. The requirement of other adjuvant drugs, total blood loss (166.40 ml vs. 251.17 ml) and extubation time were also significantly lower in the LIG group. The study concludes that intravenous Lignocaine gives a better surgical field in the first 105 min of surgery, comparable hemodynamics and decreased blood loss in patients undergoing TNES as compared to Dexmedetomidine infusion. Hence its role as an agent for controlled hypotension during TNES surgery is promising.

Tele-Otolaryngology at a Tertiary Care Center in North India During COVID-19 Pandemic Lockdown: A Validated Patient Feedback Questionnaire Based Study.

Providing medical care using the telecommunication networks holds the promise of increased access and efficiency of healthcare particularly during global emergencies like the Coronavirus disease 2019 (COVID-19) pandemic. Most of the hospital setups worldwide have put telemedicine into practice ever since the onset of the COVID-19 pandemic. This study aimed at assessing the effectiveness of Tele-otolaryngology (TO) at a tertiary care centre during the pandemic lockdown. A validated patient feedback questionnaire was developed and distributed to 2577 patients who utilised the TO mobile health service at our institute. Patient feedback-based assessment of TO effectiveness during COVID-19 lockdown was carried out. The validated questionnaire in English and Hindi was statistically robust with Cronbach's alpha value of 0.808 and 0.886 respectively. 1751 patients completed their feedback to the questionnaire. 97.5% utilised WhatsApp for TO consultation. 15.2% patients were detected of Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection with TO guidance. Up to 75% patients had a positive response to the questionnaire and 91.1% opined of savings achieved either with travel time, cost incurred or the treatment time. With respect to patient health status, 71.5% recovered, 20.1% had no change and 8.4% deteriorated with a mortality rate of 1.65%. Telehealth in otolaryngology during the COVID-19 pandemic lockdown was indispensable in managing exigencies. Redesigning of clinical protocol and technical constraints, clinician training and a validated patient feedback questionnaire would effectively bestow upon the global emergencies.

Fine needle aspiration cytology in lesions of the nose, nasal cavity and paranasal sinuses.

OBJECTIVE: To assess the spectrum of lesions in the sinonasal region diagnosed on FNAC. STUDY DESIGN: This is a retrospective audit of sinonasal lesions diagnosed on FNAC over a period of 12 years (1998-2009). RESULTS: Out of a total of 79,851 FNACs, 158 (0.2%) were from the sinonasal region. FNAC was non-diagnostic in 20 (12.6%) cases. Infective/inflammatory lesions comprised of 30 (19%) cases including non-specific inflammation (19), fungal infection (7), tuberculosis (2), actinomycosis (1) and filariasis (1). Benign cysts (24; 15.2%) included epidermal inclusion cysts, mucocele and aneurysmal bone cyst. Benign bone tumors (4) comprised of giant cell tumor, fibrous dysplasia, chondroma, and osteoblastoma. Other benign tumors included lipoma (6), hemangioma (5), schwannoma (2), meningioma (1), pleomorphic adenoma (1), sebaceous adenoma (1) and other skin adnexal tumors (3). Malignant epithelial tumors (24; 15.2%) included squamous cell carcinoma (10), basal cell carcinoma (5), poorly differentiated carcinoma (4) and metastatic carcinoma (5). Two cases of chordoma and one case each of dermatofibrosarcoma pertuberance and hemangiopericytoma were seen. Sarcomas included sarcoma, not otherwise specified (4), rhabdomyosarcoma (3), osteosarcoma (2), chondrosarcoma (2), leiomyosarcoma (1), malignant fibrous histiocytoma (1), fibrosarcoma (1) and malignant peripheral nerve sheath tumor (1). There were cases of malignant small round cell tumor (11), non-Hodgkin lymphoma (3), plasmacytoma (2) and malignant melanoma (2). CONCLUSION: A variety of non-neoplastic and neoplastic conditions can involve the sinonasal region. FNAC is a reliable diagnostic procedure in a good number of cases, especially in the light of clinico-radiological data.