Pott's puffy tumor: An unusual complication of rhino-orbito-cerebral mucormycosis.

Objective: To describe clinicoradiological features and surgical outcomes in a series of nine patients with rhino-orbito-cerebral mucormycosis (ROCM) who presented with Pott's puffy tumor (ROCM-PPT). Methods: The records of nine patients with ROCM-PPT seen between March 2020 and December 2021 were analysed. Clinical features, radiology, histopathology, operative findings, management and outcome were noted. Frontal sinus pneumatisation and outflow tract configuration was compared between patients and controls with ROCM and no PPT. Results: ROCM-PPT was diagnosed in 9 of 284 (3.2 %) patients with ROCM seen during the study period. There were six (66.7 %) males and the median age was 54 (IQR 46-60) years. Eight (88.9 %) patients had diabetes mellitus and seven (77.8 %) had been COVID-19 positive. Radiological features of osteomyelitis, subperiosteal abscess formation and dural enhancement were seen in all patients. No significant differences in pneumatisation or frontal sinus outflow tract configuration were noted between patients and controls. All patients underwent a craniectomy with frontal bone debridement and frontal sinus exteriorisation. All patients were treated with anti-fungal agents for several months. All patients had symptomatic improvement at a median follow-up of 21 (IQR 18-23) months. Repeat CT/MRI scans showed disease regression/resolution in six out of eight (75 %) patients with follow-up imaging, and stable disease in two others. Conclusions: ROCM-PPT is a rare, delayed complication of mucormycosis that was seen in larger numbers during the recent COVID-19 pandemic. Aggressive debridement of osteomyelitic bone and antifungal therapy results in a good outcome.

Aspergillosis Causing Orbital Subperiosteal Abscess in an Immunocompetent Child: A Rare Presentation.

Orbital abscesses are primarily seen in children as complication of ethmoid bacterial sinusitis. We report a case of invasive aspergillosis causing orbital abscess in an immunocompetent child which resolved with surgery followed by antifungal therapy. This case highlights need for histopathological, and microbiological examination, including fungal culture in such cases.

A Comparative Study of Acute Invasive Fungal Sinusitis During the First and Second Waves of the COVID-19 Pandemic.

We aimed to compare the demography, clinical profile, histopathology, fungal culture, radiology, surgery performed, medical therapy and outcomes of patients with acute invasive fungal sinusitis seen during the first and second waves of the COVID-19 pandemic by retrospectively reviewing their case records. Of 238 patients, 43(18.1%) presented during the first wave and 195(81.9%) during the second wave. Patients seen during the first wave were older (p = 0.04) and more likely to have visual impairment (p = 0.004), frozen eye (p = 0.012), altered sensorium (p = 0.007) and stage 3 disease (p = 0.03). Those seen during the second wave were more often COVID-19 positive and had newly diagnosed diabetes mellitus (p = 0.04)and stage 1 disease (p = 0.03). Most patients had a positive culture for Rhizopus species during both waves. Histopathology showed broad aseptate hyphae in all patients but angioinvasion was seen more often during the first wave (p = 0.04). The majority of patients were treated with endoscopic+/- open debridement followed by intravenous amphotericin B and oral posaconazole. While the overall survival rate was similar (first wave 65.1%; second wave 79%; p = 0.106), mortality after discharge was greater during the first wave (11.6% vs 1.5%; p = 0.001). Mortality was higher in patients with stage 3 disease (p = 0.003). Significant differences in clinical presentation, histopathology, radiological stage of disease and post-discharge survival were noted between the two waves of the COVID-19 pandemic, the causes for which were multi-factorial.

Threshold and suprathreshold component analysis in olfactory dysfunction: a retrospective study.

OBJECTIVE: To analyse variations in the n-butanol threshold and odour identification scores of the Connecticut Chemosensory Clinical Research Centre test in various grades of olfactory dysfunction and in different nasal conditions leading to olfactory loss. METHOD: Retrospective observational study. RESULTS: All grades of olfactory dysfunction were predominantly noted among males. In chronic rhinosinusitis, anosmia or severe hyposmia was seen in 87.5 per cent of patients without polyps in comparison with 68 per cent of patients with polyps. In addition, 90 per cent of patients with atrophic rhinitis and post-traumatic loss had anosmia, but only 30.7 per cent of patients with allergic rhinitis had anosmia. Pepper was the most affected smell for all the nasal diseases except atrophic rhinitis, in which asafoetida and baby powder smells were affected more. CONCLUSION: In most inflammatory sinonasal conditions, odour identification is relatively preserved even when the threshold is maximally affected. In patients with comparable olfactory dysfunction based on the Connecticut Chemosensory Clinical Research Centre test score, a relatively preserved suprathreshold odour identification score may predict better prognosis.

Whole genome analysis of Rhizopus species causing rhino-cerebral mucormycosis during the COVID-19 pandemic.

Introduction: Mucormycosis is an acute invasive fungal disease (IFD) seen mainly in immunocompromised hosts and in patients with uncontrolled diabetes. The incidence of mucormycosis increased exponentially in India during the SARS-CoV-2 (henceforth COVID-19) pandemic. Since there was a lack of data on molecular epidemiology of Mucorales causing IFD during and after the COVID-19 pandemic, whole genome analysis of the Rhizopus spp. isolated during this period was studied along with the detection of mutations that are associated with antifungal drug resistance. Materials and methods: A total of 50 isolates of Rhizopus spp. were included in this prospective study, which included 28 from patients with active COVID-19 disease, 9 from patients during the recovery phase, and 13 isolates from COVID-19-negative patients. Whole genome sequencing (WGS) was performed for the isolates, and the de novo assembly was done with the Spades assembler. Species identification was done by extracting the ITS gene sequence from each isolate followed by searching Nucleotide BLAST. The phylogenetic trees were made with extracted ITS gene sequences and 12 eukaryotic core marker gene sequences, respectively, to assess the genetic distance between our isolates. Mutations associated with intrinsic drug resistance to fluconazole and voriconazole were analyzed. Results: All 50 patients presented to the hospital with acute fungal rhinosinusitis. These patients had a mean HbA1c of 11.2%, and a serum ferritin of 546.8 ng/mL. Twenty-five patients had received steroids. By WGS analysis, 62% of the Rhizopus species were identified as R. delemar. Bayesian analysis of population structure (BAPS) clustering categorized these isolates into five different groups, of which 28 belong to group 3, 9 to group 5, and 8 to group 1. Mutational analysis revealed that in the CYP51A gene, 50% of our isolates had frameshift mutations along with 7 synonymous mutations and 46% had only synonymous mutations, whereas in the CYP51B gene, 68% had only synonymous mutations and 26% did not have any mutations. Conclusion: WGS analysis of Mucorales identified during and after the COVID-19 pandemic gives insight into the molecular epidemiology of these isolates in our community and establishes newer mechanisms for intrinsic azole resistance.

A Rare Case of Ameloblastic Carcinoma of Maxilla.

Ameloblastic carcinoma is an odontogenic neoplasm with combined features of ameloblastoma and carcinoma on histopathological examination. Its prognosis is dominated by risk of local recurrence and distant metastasis. We report our patient because of the rare site and to highlight the importance of early, aggressive surgical treatment and regular follow-up.

Relationship of Upper Airway Collapse with Severity of Sleep Apnoea and Sleepiness.

Introduction: Obstructive sleep apnoea (OSA) is characterized by repeated episodes of upper airway collapse. A review of literature shows limited and conflicting data regarding impact of upper pharyngeal collapse on severity of OSA and degree of sleepiness. Objective: To evaluate the association of the number of levels and degree of upper airway collapse and severity of OSA. Methods: This is a retrospective study including all patients with OSA over a two-year period. Data regarding neck circumference (NC), body mass index (BMI), nasopharyngolaryngoscopy with Muller's manoeuvre, Epworth sleepiness scale (ESS) questionnaire and a full night polysomnography were collected. Correlation of the number of sites involved and degree of collapse at each site (velum, lateral pharyngeal wall- Level I, base of tongue - Level II and epiglottis - Level III) with BMI, NC, AHI and ESS were assessed. Results: Of the 144 patients, 98% had collapse at Level I. 80% of patients had multisegmental collapse with 30% having collapse at all three levels. The number of levels and the severity of collapse did not have a proportionate effect on the AHI and ESS and were not directly dependent on the BMI. However, changes in NC had a significant effect on the severity of collapse.Conclusion: Severity of OSA and degree of sleepiness were not directly dependent on the severity and the number of levels of collapse. Since majority of the patients had multi segmental collapse, the study highlights the importance of careful assessment of all levels to tailor management strategies for optimum patient management.

Short intravenous amphotericin B followed by oral posaconazole using a simple, stratified treatment approach for diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis: a prospective cohort study.

OBJECTIVES: To evaluate the efficacy and safety of short-course intravenous amphotericin B followed by sustained release posaconazole tablets for diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis. METHODS: This prospective, pragmatic study included adults with diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis. Patients received short (7-14 days) or long (15-28 days) intravenous antifungal therapy (short intravenous antifungal treatment [SHIFT] or long intravenous antifungal treatment [LIFT], respectively) depending on the presence or absence of brain involvement. All patients received step-down posaconazole tablets, debridement, and glycemic control. The primary outcome was the treatment success at week 14, which was determined by assessing survival and the absence of disease progression through clinical evaluation and nasal endoscopy. Log-binomial regression analysis (risk ratio and 95% CI) was performed to assess factors associated with the primary outcome. RESULTS: Intravenous therapy was administered to 251 participants: SHIFT, 205 (median duration, 13 days); LIFT, 46 (median duration, 22 days). Treatment success at 3 months was 88% (217/248; 95% CI, 83-91%): SHIFT group, 93% (189/203; 89-96%); LIFT group, 62% (28/45; 47-76%). All-cause mortality was 12% (30/251): SHIFT group, 6% (13/205); LIFT group, 37% (17/46). Age (aRR [95% CI]: 1.02 [1.00-1.05]; p 0.027), diabetic ketoacidosis at presentation (2.32 [1.20-4.46]; p 0·012), glycated haemoglobin A1c (1.19 [1.03-1.39]; p 0.019), stroke (3.93 [1.94-7.95]; p 0·0001), and brain involvement (5.67 [3.05-10.54]; p < 0.0001) were independently associated with unsuccessful outcomes. DISCUSSION: Short intravenous amphotericin B with step-down posaconazole tablets should be further studied as primary treatment option for diabetes or COVID-19-associated mucormycosis in randomized controlled trials.

Clinicopathological predictors of repeated recurrence in sinonasal inverted papilloma.

PURPOSE: To evaluate association between clinical and pathological findings and repeated recurrence in sinonasal inverted papilloma. METHODS: Retrospective cohort study conducted at a tertiary care teaching hospital included all patients operated for inverted papilloma from January 2010 to December 2019. Patients were categorized as primary and recurrent cases. Based on disease status at follow-up, they were subcategorized into 'primary with no recurrence' (PnR), 'primary with recurrence' (PwR), 'recurrent with no further recurrence' (RnR), and 'recurrent with further recurrence' (RwR) groups. Data including demography, clinical, endoscopic and pathological findings were collected and analyzed. RESULTS: Increased incidence of pale appearance of lesion in RnR group (p = 0.017), polypoidal appearance in primary group (p = 0.002) and fibrous appearance in the recurrent group (p = 0.002) were statistically significant. Predominant epithelium was combined respiratory and squamous epithelium in primary and recurrent groups and also in RnR group (p = 0.019), while it was squamous (p = 0.024) in RwR group. Epithelial hyperplasia was more common in primary and RnR groups. Oncocytic change, cystic dilatation, microabscess and squamous metaplasia were seen more in recurrent and RnR groups. Cytoplasmic glycogenation was more in recurrent and RwR groups. Stroma was predominantly edematous in all the groups. CONCLUSIONS: Patients with recurrence are younger and present earlier than those with primary disease. Fleshy appearance and pink/red colour of tumour, lining epithelium being squamous and cytoplasmic glycogenation could be considered as features predicting recurrence. Negative predictors of recurrence of IP include pale appearance of tumour, combined respiratory and squamous epithelium lining and squamous metaplasia.

Optimizing Surgical Management of Acute Invasive Fungal Sinusitis.

Objective: Early surgical debridement is vital for favorable outcomes in acute invasive fungal sinusitis (AIFS). Our study aimed to propose guidelines with tailored, conservative surgical procedures based on areas of involvement and evaluate their usefulness in avoiding repeated debridement. Methods: This retrospective observational study was conducted on 150 AIFS patients operated on with the proposed surgical guidelines from May to June 2021 at a tertiary care hospital. Data including demography, comorbidities, surgical procedures, revision surgery, and outcome were collected and analyzed. Results: All 150 patients underwent bilateral endoscopic sinonasal debridement. Among them, 108 patients (72%) had current or recent coronavirus disease (COVID) infection. Ninety-two patients (61.3%) required additional procedures based on disease extent. Twenty patients (15.4%) required revision debridement because of progressive or recurrent disease. Mean age of this group was 46.15 (standard deviation ±11.2) years with a strong male predominance (9:1). Seventeen had diabetes mellitus, 12 suffered from active COVID-19 infection and six had received corticosteroids. None of the 31 patients who had recovered from COVID-19 or had no comorbidities required revision surgery. Age, gender, and comorbidities were not significant predictors for revision surgery. Fourteen patients (70%) underwent second surgery within one month of primary surgery. Predominant disease locations were alveolus and palate (55% each), and in 80% the site was uninvolved at primary surgery. The most common revision procedure was inferior partial maxillectomy (60%). At follow-up, all were asymptomatic with no evidence of disease. Conclusion: The proposed surgical guidelines for AIFS allow for adequate surgical debridement with preservation of optimum functional status. Low revision surgery rates and good outcomes with minimal morbidity validate its usefulness.

Construct and Validation of a Three-Dimensional Physical Model for Training in Transnasal Office Procedures.

Most simulation models in rhinology are costly and are primarily meant to enhance endoscopic surgical skills. The present study aimed to construct a 3-dimensional model of the nose which is easily constructible with commonly available low cost plaster of Paris (POP) and assess its usefulness in training residents in basic transnasal procedures. A nose model was created using plaster of Paris and assessed for face and content validity by experts in rhinology while a construct validation was performed on five specified tasks by residents. All experts agreed with the resemblance of 10 of the 13 anatomical landmarks in the POP model and its utility in teaching basic transnasal procedures. There was a statistically significant difference in the time taken by I and III year residents in performing a diagnostic nasal endoscopy (p = 0.007), anterior nasal packing with polyvinyl alcohol tampon (p = 0.007), posterior nasal packing with Foley's catheter (p = 0) and nasopharyngeal swabbing (p = 0.025). This study demonstrates the construct of a low cost 3-dimensional POP model and validates its utility in training residents in routine transnasal rhinological procedures. Face and content validation showed a high degree of resemblance to human anatomy with good agreement that this model could increase resident competency. The significant difference in time taken by residents at various levels of experience in performing rhinological procedures also confirmed a reliable construct validity. The described model could be an affordable and easily constructible alternative tool to other simulation models in otorhinolaryngology residency programs especially in developing countries.

Oxygen desaturation index as alternative parameter in screening patients with severe obstructive sleep apnea.

Objectives: Assess reliability of oxygen desaturation index (ODI) as an alternative parameter to apnea hypopnea index (AHI) in screening patients with severe obstructive sleep apnea (OSA). Material and Methods: Retrospectively two-year data on demography, anthropometric features, polysomnography (PSG) parameters [AHI, ODI, minimum oxygen saturation (SpO2), mean SpO2], and Epworth sleepiness score (ESS) were collected and analyzed. Results: Study showed significant correlation of ESS with AHI, ODI, apnea-hypopnea percentage of sleep period time (AH%SPT), mean SpO2 and minimum SpO2 with highest correlation being with AHI. A Cohen's weighted Kappa analysis showed good concordance of 87.32% between AHI and ODI in classifying severity of OSA, with a significant R2 correlation of 0.84 on linear regression. An ODI>20 has a sensitivity of 96.6% and specificity of 69.6% in diagnosing severe OSA. Conclusion: Good concordance between AHI and ODI makes nocturnal oximetry a less expensive tool to confdently screen patients with severe OSA.

Characteristics of Chronic Rhinosinusitis with Nasal Polyps Based on Allergic Mucin and Fungal Elements in Patients Undergoing Revision Endoscopic Sinus Surgery.

This study sought to document the features in chronic rhinosinusitis with nasal polyp (CRSwNP) patients undergoing revision endoscopic sinus surgery (RESS), based on presence or absence of allergic mucin (AM) and fungal elements (F). A retrospective chart review of RESS cases collected Lund Mackay score (LMS), endoscopic, microbiological, histopathological, surgical and follow-up data of these patients. Patients were categorised into AM + F +, AM + F-, AM-F + and AM-F- subgroups based on the presence or absence of AM and F. The total serum IgE was significantly higher (p > 0.001) in the AM + F + subgroup. Other factors analysed including LMS, duration from previous surgery, comorbidities, degree of inflammation and disease recurrence showed no specific predilection among subgroups. Patients with a retained middle turbinate showed lesser (p = 0.04) recurrence on follow-up. Subgroups of recurrent CRSwNP showed similar characteristics and had further disease recurrence which was independent of allergic mucin and fungal elements. The presence of an intact healthy middle turbinate could reduce early disease recurrence following RESS.

Frontoethmoidal Extranasopharyngeal Angiofibroma With Orbital Pyocele.

Significance StatementExtranasopharyngeal angiofibromas (ENA) are rare vascular tumors that do not conform to the clinical characteristics of typical nasopharyngeal angiofibromas. We present the management of an angiofibroma in a rare site, within the frontal sinus with a concomitant orbital pyocele, which was completely excised via an endoscopic approach. ENAs should be considered as a differential diagnosis in patients with sinonasal mass and epistaxis. Awareness of this rare entity will avoid radical surgery thus decreasing postoperative morbidity.

Covid 19 Pandemic-Training of Healthcare Workers in Obtaining a Nasopharyngeal Swab: Our Experience.

To describe the training of healthcare workers (HCW) in nasopharyngeal swabbing during the COVID 19 pandemic. STUDY DESIGN: Retrospective study. SETTING: Tertiary care teaching hospital. SUBJECTS AND METHODS: One hundred and seventy eight health care workers were trained from May 2020 to January 2021. Three modules were designed to train the health care workers in the technique of obtaining a nasopharyngeal swab specimen.Training consisted of an instructional video on how to perform nasopharyngeal swabs and live demonstration followed by hands-on supervised training. The trainees included 30 doctors, 101 nurses, 31 respiratory therapists, 3 physiotherapists, 9 interns and 4 lab technicians. There were 39 male and 139 female trainees. After attending all 3 modules of training, they were confident and efficient in taking a non-traumatic nasopharyngeal swab. Good knowledge and adequate training is key to a good nasopharyngeal sampling for SARS CoV-2 testing.