Baseline findings of a multicentric ambispective cohort study (2021-2022) among hospitalised mucormycosis patients in India.

In India, the incidence of mucormycosis reached high levels during 2021-2022, coinciding with the COVID-19 pandemic. In response to this, we established a multicentric ambispective cohort of patients hospitalised with mucormycosis across India. In this paper, we report their baseline profile, clinical characteristics and outcomes at discharge. Patients hospitalized for mucormycosis during March-July 2021 were included. Mucormycosis was diagnosed based on mycological confirmation on direct microscopy (KOH/Calcofluor white stain), culture, histopathology, or supportive evidence from endoscopy or imaging. After consent, trained data collectors used medical records and telephonic interviews to capture data in a pre-tested structured questionnaire. At baseline, we recruited 686 patients from 26 study hospitals, of whom 72.3% were males, 78% had a prior history of diabetes, 53.2% had a history of corticosteroid treatment, and 80% were associated with COVID-19. Pain, numbness or swelling of the face were the commonest symptoms (73.3%). Liposomal Amphotericin B was the commonest drug formulation used (67.1%), and endoscopic sinus surgery was the most common surgical procedure (73.6%). At discharge, the disease was stable in 43.3%, in regression for 29.9% but 9.6% died during hospitalization. Among survivors, commonly reported disabilities included facial disfigurement (18.4%) and difficulties in chewing/swallowing (17.8%). Though the risk of mortality was only 1 in 10, the disability due to the disease was very high. This cohort study could enhance our understanding of the disease's clinical progression and help frame standard treatment guidelines.

Coronavirus Disease 2019 (COVID-19)-Associated Rhino-Orbito-Cerebral Mucormycosis: A Multi-Institutional Retrospective Study of Imaging Patterns.

BACKGROUND: Mucormycosis infection of the maxillofacial region and brain has been associated with coronavirus disease 2019 (COVID-19) infection. Mucormycosis was relatively a rare infection before COVID-19, and imaging findings are not very well described. MATERIALS AND METHODS: A retrospective imaging study of 101 patients diagnosed with COVID-19-associated mucormycosis by histopathology and/or culture was performed. All patients underwent computed tomography and/or magnetic resonance imaging based on the clinical condition of the patient and on consensus decision by the team of treating physicians. A simple 3-stage classification system based on imaging findings was adopted. RESULTS: One hundred one cases were included in the final analysis (mean age = 55.1 years; male/female ratio = 67:34). The affected patients had diabetes in 94% of the instances (n = 95), 80.1% (n = 81) received steroids), whereas 59.4% (n = 60) patients received supplemental oxygen. The majority underwent surgical intervention, whereas in 6 cases, patients were treated with antibiotic regimens. Sixty subjects improved following therapy, whereas 18 eventually succumbed to the illness. We noted a significant positive correlation between the imaging stage and outcomes. No association was seen between other clinical parameters and final clinical outcomes. Salient imaging findings include lack of normal sinonasal mucosal enhancement, perisinus inflammation, ischemic optic neuropathy, perineural spread, pachymeningeal enhancement, and presence of strokes. CONCLUSIONS: We describe the imaging findings in the largest cohort of patients with rhino-orbito-cerebral mucormycosis in the context of the current COVID-19 pandemic. A simplified staging system described here is helpful for standardized reporting and carries prognostic information.

Online Registry of COVID-19-Associated Mucormycosis Cases, India, 2021.

We established an online registry of coronavirus disease-associated mucormycosis cases in India. We analyzed data from 65 cases diagnosed during April-June 2021, when the Delta variant predominated, and found that patients frequently received antibacterial drugs and zinc supplementation. Online registries rapidly provide relevant data for emerging infections.

Quality-of-life changes following three-dimensional printing of prosthesis for large nasal septal perforations-Our experience of 13 patients.

Nasal septal perforations can be caused by a number of aetiology including intra-nasal drug abuse, trauma and iatrogenic causes.

Optimal Management of Allergic Fungal Rhinosinusitis.

INTRODUCTION: Allergic fungal rhinosinusitis (AFRS) is a chronic disorder with significant morbidity and a high recurrence rate needing long-term follow-up. Even after its first description many decades ago, there is still considerable uncertainty about the management of this condition. DESCRIPTION: In this chapter, we breakdown the topic "Optimal management of allergic fungal rhinosinusitis" into sub-headings in order to discuss the latest research and available literature under each topic in great detail. Every attempt has been made to incorporate the highest level of evidence that was available at the time of writing. SUMMARY: Pre-operative diagnosis and further management prior to surgery is important. Steroids help in reducing inflammation and help improve the surgical field. Surgery remains the mainstay in the management of this condition along with long-term medical management. Oral steroids are reserved for acute flare-ups in the background of associated lung concerns. Oral and topical antifungal agents have no role in the control of the disease. Biological agents are being prescribed predominantly by respiratory physician colleagues, mainly for the control of the chest-related issues rather than for sinus disease. Immunotherapy as an adjunct with surgery is promising. CONCLUSION: AFRS is a disease with many variables and a wide range of symptomatic presentation. It takes a keen clinician to identify the disease and subsequently manage the condition. Treatment involves long-term follow-up with early detection of recurrence or flare-ups. Any of the mentioned modalities of management may be employed to effectively control the condition, and treatment protocols will have to be tailor-made to suit each individual patient. Various medications and drugs such as Manuka honey, antimicrobial photodynamic therapy, hydrogen peroxide and betadine rinses appear to be promising. More robust studies need to be undertaken to ascertain their routine use in clinical practice.

Adjunctive techniques to improve access of the endoscopic prelacrimal recess approach.

OBJECTIVES: To determine whether adjunctive surgical techniques could improve access of instruments provided by the endoscopic prelacrimal recess approach to the anatomical boundaries of the maxillary sinus, and pterygopalatine and infratemporal fossa. METHODS: Ten fresh-frozen adult cadaver heads were utilized. The anatomical areas of interest were fixed, bony boundaries of the maxillary sinus, infratemporal fossa, and pterygopalatine fossa: alveolar recess (AR), zygomatic recess (ZR), perpendicular plate of the palatine bone (PB), ascending ramus of mandible (RM), floor of the orbit medial and lateral to infraorbital nerve (M-ION and L-ION, respectively). Access to the areas were compared using standard sinus surgery instruments (straight and 45° forceps) introduced via the prelacrimal recess approach, trans-septal window and canine fossa puncture. RESULTS: The prelacrimal recess approach successfully provided access to the PB and M-ION in >90% of dissections when using both the straight and 45° forceps. With the straight forceps, the ability to successfully access to the AR and ZR was the lowest at 50% and 35% respectively, although improving to 75% and 60% respectively with the 45° forceps. Access to the AR, ZR, and L-ION improved significantly when the 45° forceps was introduced through the trans-septal window. Frequency of access to the RM when either instruments when introduced through the canine fossa puncture was no greater than 60% of the dissections. CONCLUSIONS: The addition of a small trans-septal window for instruments significantly improved access of the prelacrimal recess approach especially to the orbital floor, lateral margins of the maxillary sinus, and retromaxillary space. LEVEL OF EVIDENCE: 4 Laryngoscope, 130: 1857-1863, 2020.

Surgical Techniques for the Correction of Postrhinoplasty Depressed Scars on the Nasal Tip.

IMPORTANCE: Augmentation rhinoplasty is common in the Asian population and the lack of suitable autologous material for augmentation has led to the use of alloplastic materials. Many of these patients develop complications, including a depressed dimple-like scar of the nasal tip. Causes of such dimpling include the use of large implants, infection, extrusion, and surgeon incompetence. OBJECTIVE: To describe the various techniques that can be used to correct dimpling of the nasal tip. DESIGN, SETTING, AND PARTICIPANTS: Data were retrospectively reviewed from 28 patients who had undergone surgical procedures from January 1, 2013, through July 31, 2014, in a rhinoplasty clinic in Seoul, Korea, for the correction of a contracted nose with nasal scars secondary to previous rhinoplasties. Data analysis was conducted from August 1, 2014, through February 16, 2015. INTERVENTIONS: Before surgery, a complete rhinological examination was conducted, digital photographs were taken, and an assessment was made regarding the severity of the dimpling, the condition of the nasal skin, and the underlying supporting structures. Based on these factors, the appropriate type of procedure was planned. MAIN OUTCOMES AND MEASURES: Patient satisfaction with change after surgery was assessed using a 3-point Likert scale (3 indicates satisfied; 2, fairly satisfied; and 1, dissatisfied). Outcomes were also reviewed by 2 surgeon-peers who gave an outcome score ranging from 1 to 10 (1 indicates a poor cosmetic outcome; 10, the best possible outcome). RESULTS: The nasal contour and tip symmetry were restored to aesthetic standards with these relatively simple techniques. Eleven patients (39.2%) were treated with unilobed flap, 4 (14.2%) with a bilobed flap, 3 (10.7%) with Z-plasty, 9 (32.1%) with soft-tissue interposition, and 1 (3.5%) with a transposition flap. Twenty-four of the 28 patients (85.7%) were satisfied with their outcomes and 4 (14.3%) patients were dissatisfied and were given a revision procedure, following which they were satisfied with their outcomes. The follow-up period ranged between 6 to 32 months (mean, 12.3 months). The mean surgeon-reviewed outcome score for soft-tissue interposition procedure was 8.0 of 10; for the unilobed flap, 8.0 of 10; for the bilobed flap, 7.5 of 10; for the transposition flap, 8.0 of 10; and for Z-plasty, 7.8 of 10. CONCLUSIONS AND RELEVANCE: These techniques are reproducible and the choice of the technique depends on the shape, size, and location of the scar; skin condition; patient expectations; and the surgeon's experience and comfort level with the procedure. LEVEL OF EVIDENCE: 4.

The Seesaw Technique for Correction of Vertical Alar Discrepancy.

Alar vertical discrepancy including alar base has been viewed as one of the most challenging reconstructive problems in rhinoplasty. The authors have created a simple technique that consistently gives aesthetically acceptable results. The authors have designed the seesaw technique to correct alar discrepancy (type 1 to 3). Type 1 has been used in 14 patients, type 2 has been used in three patients, and type 3 has been used in seven patients. Alar discrepancy was corrected satisfactorily in all cases, with good cosmetic outcome. One case required scar revision and another case required revision for overcorrection; satisfactory results were ultimately achieved in both cases. This new technique is quite easy to design and is effective in the correction of alar discrepancy. It yields good postoperative results along with satisfactory aesthetic outcomes.