A Meta-analysis of Surgical Outcomes of T4a and Infranotch T4b Oral Cancers.

OBJECTIVE: To determine the overall surgical outcomes of infranotch T4b oral cancers and compare them with T4a oral cancers. METHODS: PubMed, EMBASE and Cochrane databases from 2000 to 2022 were systematically searched. Clinical studies reporting at least one outcome following curative surgery and adjuvant therapy for comparison of patients with either infranotch T4b (IN-T4b) or T4a tumour. The heterogeneity of the included studies was determined using Tau-squared, Chi-squared, and the Higgins I2 test. The random effects model was used to determine the log odds ratio (logOR). RESULTS: The systematic review comprised 11,790 patients from 16 included studies. Seven studies were included in the meta-analysis (n = 11,381). For IN-T4b patients, the pooled 2 and 5 year overall survival (OS) were 59.3% and 53.2%, 2 and 5 year disease-free survival (DFS) 57.9% and 48.4%, 2 and 5 year disease-specific survival (DSS) 72% and 68%, and 2 and 5 year local control (LC), 47% and 56%, respectively. There was no statistically significant difference in 2 year OS [logOR = 0.28 (-0.47, 1.03), p = 0.46, confidence interval (CI) = 95%], 5 year OS [logOR = 0.7 (-0.4, 1.8), p = 0.54, CI = 95%], 2 year DFS [logOR = 0.22 (-0.35, 0.79), p = 0.45, CI = 95%], 5 year DFS [logOR = 0.17 (-0.42, 0.77), p = 0.57, CI = 95%], 2 year LC [logOR = 0.47 (-0.33, 1.26), p = 0.25, CI = 95%] and 5 year LC [logOR = 0.34 (-0.31, 0.99), p = 0.31, CI = 95%] between IN-T4b and T4a oral cancers. CONCLUSION: Results of this meta-analysis suggest that IN-T4b oral cancers have similar outcomes to T4a oral cancers, which supports down-staging IN-T4b cancers to T4a cancers.

Skull Base Involvement in Covid Associated Rhino-Orbital-Cerebral Mucormycosis: A Comprehensive Analysis.

The base of skull forms the first line of barrier to be breached in the transition of rhino-orbito-palatal forms of mucormycosis to intracranial forms with various neurological deficit. The pattern of base of skull erosion has prognostic implications in overall recovery and survival of the patient. The aim of the study was to assess the pattern of skull base involvement in cases of rhino-orbital-cerebral mucormycosis (ROCM) in terms of clinical presentations, radiological findings, intraoperative illustrations and post operative recovery. This is a retrospective single centre study of Covid associated Mucormycosis (CAM) patients with skull base involvement at a tertiary referral centre of central India from May 2021 to October 2021. Amongst a total of 248 patients of CAM, 54 patients with skull base involvement were included in our study. The cases were stratified into basifrontal-BF (15%), basisphenoid-BS (20%), orbital apex-OA (15%), basiocciput-BO (26%), frontal bone osteomyelitis-FBO (22%) and sphenoid bone osteomyelitis-SBO (2%), based on their pattern of involvement of skull base and intracranial spread. Early ethmoid and cribriform plate involvement progressed to frontal lobe abscess while early maxillary disease progressed to developed temporal lobe abscess. The orbital apex lesions had early onset cavernous sinus thrombosis. Analysis of clinical manifestations and postoperative follow up revealed an emerging pattern where Posterosuperior lesions of paranasal sinuses (Ethmoid, roof of maxilla and orbit) progressing to BF, BS, OA, FBO and SBO had poorer treatment outcome than Anteroinferior (Floor of maxillary sinus, palate) based lesions which involved BO of skull base. The inferiorly located diseases had better prognosis, less duration of hospital stay, lesser mortality and decreased need for second surgery. There exists a temporal relation of the initial site of fungal load in sinonasal region to their subsequent intracranial spread. Classification into subtypes helped in disease stratification which helped in prognostication and surgical planning. Early intervention by multidisciplinary team improved survival outcome.

Transillumination and Point-of-Care Ultrasonography to Delineate Tracheal Deviation for Challenging Tracheostomy: A Case Report.

Tracheostomy is indicated for varied reasons and is a relatively safe procedure that can be done with both open and percutaneous methods. However, the procedure is often challenging in cases of distorted neck anatomy. Neck swellings often push the trachea laterally or shield it. Even some gross intrathoracic pathology may shift the trachea from the typical trajectory making it challenging to delineate the course of the trachea. A bedside point-of-care technique having a visual aid that can guide the performer thus appears beneficiary. Fiber-optic assistance for correct puncture and confirmation is known, and light-based techniques have been used for tracheostomies. As fiberscopes are not infrequent in tertiary and even secondary care hospitals, transillumination from a flexible bronchoscope can identify the altered course of the trachea, much like a navigation system, and systematically aid the performer in steering away from the obstacles. We present two cases in two scenarios with tracheal deviation who underwent either open or percutaneous tracheostomy with point-of-care ultrasound and transillumination to delineate the course of the trachea and facilitate difficult tracheostomies safely.

Mortality and its determinants after an outbreak of post COVID-19 associated rhino-orbito-cerebral mucormycosis in Central India.

AIM: To report cumulative mortality rates using survival analysis from an outbreak of 211 patients with post COVID-19 rhino-orbito-cerebral mucormycosis (ROCM) in central India. METHODS: Case files of eligible patients were evaluated and mucor was identified from deep nasal swabs using freshly prepared KOH mount. All patients underwent contrast enhanced MRI and disease staging was done based on the extent of anatomical involvement. All patients received intravenous Amphotericin B and sinus debridement was done when possible. Orbital exenteration was reserved for patients with advanced orbital disease. RESULTS: The mean age was 50.7 ± 10.2 of which 147 (70%) were men. At presentation, ROCM was limited to sinuses in 72 (34%), orbital extension was seen in 102 (48%) and 31 (15%) had CNS extension. Sinus debridement was possible in 82% cases (n = 173). Thirty-five (16.6%) patients died due to ROCM. The mean follow-up of patients who survived was 126.6 ± 16.4 days. The cumulative mortality rate at day 10 was 4.8% (95%CI = 2.6-8.8%) and increased 13.1% (95%CI = 9.1-18.7%) at day 30 and to 18.4% (95%CI = 13.6-24.8%) at day 60. Majority of deaths (n = 26, 75%) occurred within 1-month of ROCM presentation. Multivariable hazards analysis showed that patients with CNS involvement had a 6.5 times higher risk of death (Hazard Ratio = 6.71, 95% CI = 2.9-15.5, p < 0.001). CONCLUSION: We report significantly lower mortality rates compared to recent literature that varies from 30 to 80% at 1-month follow-up. Timely sinus debridement and systemic Amphotericin B can help reduce mortality. Presence of CNS extension significantly increased the mortality risk with patients with ROCM.

Impact of cancer diagnosis on use of smokeless tobacco: A descriptive study of patient-relative dyads.

Background: The time of cancer diagnosis is considered as a teaching moment with regard to tobacco cessation. Aim: In view of the limited studies focussing on smokeless tobacco (SLT), we aimed to assess the patterns of SLT use, attitudes toward SLT use in the context of cancer diagnosis, and factors associated with quitting SLT in dyads consisting newly diagnosed patients with head and neck cancers and their relatives. Material and Method: A total of 106 such dyads were assessed on cross-sectional study design. The patients included in the study were above 18 years of age of either sex with a recent (i.e., <6 months) diagnosis of head and neck (lip, tongue, mouth, oropharynx, hypopharynx, pharynx, and larynx) cancer (HNC), not having undergone any surgical intervention for the same and having used SLT for at least 6 months continuously prior to diagnosis of HNC. For each patient, one family member who was aged 18 years or above and lived for at least past 1 year with the patient was included. Result: We found that 60.4% of patients and 6.53% of relatives quit SLT use after the diagnosis of cancer. However, motivation to quit was greater despite continued SLT use, in both patients and relatives. Reasonable number of patients and relatives reported awareness regarding health warnings and long-term consequences of SLT use on cancer. For patients, use of only one form of SLT, presence of 2 or more males in the family using SLT, and presence of another tobacco-related medical disorder in the family were significantly higher in those who quit. Conclusion: The diagnosis of cancer might indeed act as a "teaching moment" for many users but this effect is not extendable on to their relatives.

Effect of Two Different Tranexamic Acid Doses on Blood Loss in Head and Neck Cancer Surgery: A Randomized, Double-Blind, Controlled Study.

Background and aim Head and neck cancer is frequent, and surgeries pose more significant morbidity and mortality due to multitudinal causes; heavy blood loss and transfusion are among them. Tranexamic acid (TXA) is known to stabilize the micro clots hence controlling excessive blood loss. The present study aimed to compare perioperative blood loss with two different doses of TXA and placebo to find the effectiveness and optimal dose. Methods With ethical approvals and informed consent, the present prospective, randomized, double-blind, controlled study was conducted in a teaching institute from May 31, 2018, to Dec 28, 2019. Patients undergoing elective head and neck cancer (HNC) surgeries were included. Preoperative Hb < 7 gm% or > 16 gm%, known coagulopathy, anticoagulant therapy, contraindications to TXA, intraoperative torrential or blood loss due to arterial injury were excluded. Group T-1 received TXA 10mg/kg, T-II received 15 mg/kg, while the control group (Gr-C) received equal volume normal saline. Data about demography, surgical time, intraoperative and postoperative blood loss, and transfusion were collected and compared. SPSS software was used for analysis; p-value <0.05 was considered significant. Results Ninety patients were screened, 84 completed the study. All three groups were similar in demographics. The median blood loss with 25th -75th percentile in group C, T-I, and T-II groups were 762.5 (513.5-1193), 541.5 (296.5-787), and 536.0 (180.5 - 879) mL, respectively; p: 0.025. There was a significant difference between the control group and T-I (p-value: 0.0153), and control and T-II (p-value: 0.0248), but an insignificant difference between T-I and T-II (p-value: 0.706). 5 (17.85%) in each of T-I and T-II required transfusion, whereas 14 (50%) in the control group required it; p < 0.011). No major clinically significant related to study drugs were noted. Conclusion Compared to placebo (normal saline), preoperative administration of TXA in bolus significantly reduced perioperative blood losses and transfusion requirement in patients undergoing HNC surgery as estimated using the Hb-based method. A bolus dose of doses of 10mg/kg and 15 mg/kg is equally effective.

Cryosurgery Vs Trichloroacetic Acid Chemical Cautery for the Treatment of Hypertrophied Nasal Turbinate: A Comparative Study.

INTRODUCTION: The Study Aimed To Compare The Results of Cryosurgery With Trichloroacetic Acid Chemical (TCA) Cautery For The Treatment of Hypertrophied Nasal Turbinates. MATERIALS AND METHODS: This was a prospective study of 70 patients with nasal obstruction due to hypertrophied nasal turbinates who were randomly divided in 2 groups of 35 each. In group 1, patients underwent inferior nasal turbinate reduction by cryosurgery and in group 2 patients with cautery by 50 % TCA. The patients were evaluated using SNOT-20 score pre and postoperatively on 6th month. RESULTS: Significant improvement in symptoms was seen in 28 patients (80 %) in group 1 and in 10 patients (28.57%) in group 2..Improvement in average SNOT Score after cauterization of hypertrophied nasal turbinates by cryosurgery was from 55(severe) to 16(mild) and by TCA was from 54(severe) to 32(mod) in 6 months and this was statistically significant (P<0.001). Complications like bleeding, scarring, infection and adhesion formation were more with TCA than that of cryosurgery group and among these complications scarring was statistically significant (P =0.003). CONCLUSION: The use of cryosurgical treatment for hypertrophied nasal turbinates is a safe, curative method as compared to that of TCA cautery which is less curative and with more complications.

Audiological Abnormalities in Vitiligo Patients: A Hospital-Based Cross-Sectional Study

Abstract Introduction There are some discrepancies in the literature about the influence of vitiligo on auditory functions. According to some authors, vitiligo influences hearing, whereas others question such influence. Therefore, we conducted a study to evaluate audiological functions in vitiligo patients. Objectives To determine the effect of vitiligo on auditory functions. Methods A hospital-based observational study was done from January 2017 to July 2017. Clinically diagnosed cases of vitiligo were enrolled for the study. A complete otological examination was conducted in all patients. Results Fifty-two patients (male: female 28:24) were included in the study. Ten patients (19.2%) had sensorineural hearing loss (SNHL). Seven patients (13.5%) had bilateral and 3 (5.7%) had unilateral SNHL. High frequency loss was seen in 17 out of 20 ears (10 affected patients), 6 ears had both low and high-frequency hearing loss. Of 12 ears with speech frequency involvement, mild hearing loss was seen in 5 and moderate to severe in 1 ear.Most cases of SNHL were detected in the age group 41 to 60 years old (63.6%), which was statistically significant (p-value 0.00). Conclusion The results of this study suggest that vitiligo patients require routine monitoring for auditory functions for early identification of SNHL. Older subjects with vitiligo might be at a higher risk for audiological abnormalities. These patients should also be informed regarding the associated risk with noise and ototoxic drug exposure.

Audiological Abnormalities in Vitiligo Patients: A Hospital-Based Cross-Sectional Study.

Introduction There are some discrepancies in the literature about the influence of vitiligo on auditory functions. According to some authors, vitiligo influences hearing, whereas others question such influence. Therefore, we conducted a study to evaluate audiological functions in vitiligo patients. Objectives To determine the effect of vitiligo on auditory functions. Methods A hospital-based observational study was done from January 2017 to July 2017. Clinically diagnosed cases of vitiligo were enrolled for the study. A complete otological examination was conducted in all patients. Results Fifty-two patients (male: female 28:24) were included in the study. Ten patients (19.2%) had sensorineural hearing loss (SNHL). Seven patients (13.5%) had bilateral and 3 (5.7%) had unilateral SNHL. High frequency loss was seen in 17 out of 20 ears (10 affected patients), 6 ears had both low and high-frequency hearing loss. Of 12 ears with speech frequency involvement, mild hearing loss was seen in 5 and moderate to severe in 1 ear. Most cases of SNHL were detected in the age group 41 to 60 years old (63.6%), which was statistically significant ( p -value 0.00). Conclusion The results of this study suggest that vitiligo patients require routine monitoring for auditory functions for early identification of SNHL. Older subjects with vitiligo might be at a higher risk for audiological abnormalities. These patients should also be informed regarding the associated risk with noise and ototoxic drug exposure.

Disseminated Cutaneous Rhinosporidiosis.

A 41-year-old man from the state of Chhattisgarh, India, had a previous history of nasopharyngeal rhinosporidosis for 27 years, for which he had surgical intervention seven times, most recently endoscopically 2 months earlier. For the last 8 months, he had noticed skin lesions on the shoulders and forehead. Of interest was a history of bathing in ponds as a child. Examination revealed a soft, skin-colored, strawberry-shaped papule on the forehead (Figure 1A), a papule with a hemorrhagic crust on the left shoulder (Figure 1B), and a crusted friable plaque on the right shoulder (Figure 1C). Endoscopy revealed a 1 cm × 1 cm red polypoidal mass on the lateral wall of the nasopharynx. A diagnosis of disseminated cutaneous rhinosporidiosis with nasal-nasopharyngeal rhinosporidiosis was considered.

Transnasal Stabilization in Naso-orbito-ethmoid Fractures: The Easy Way!

Effective management of naso orbito ethmoidal fractures involves both functional and esthetic correction. While functional correction is routinely achieved, in our experience, most secondary deformities resulted from inadequate nasal bridge projection. We hereby suggest a simple technique to stabilize the nasal bridge after mild overcorrection thereby improving the esthetic outcome in naso orbito ethmoidal fractures.