A fungal epidemic amidst a viral pandemic: Risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis in India.

PURPOSE: To study the risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis (ROCM) during the COVID-19 pandemic in India. METHODS: Multi-centric retrospective case-control study conducted from October 2020 to May 2021. Cases comprised of consecutive patients of COVID-19-associated ROCM (CA-ROCM) presenting at the participating ophthalmic institutes. Controls comprised of COVID-19-positive or COVID-19-recovered patients who did not develop ROCM. Comparative analysis of demographic, COVID-19 infection, treatment parameters and vaccination status between cases and controls performed. Clinical and imaging features of CA-ROCM analyzed. RESULTS: There were 179 cases and 361 controls. Mean age of presentation in cases was 52.06 years (p = .001) with male predominance (69.83%, p = .000011). Active COVID-19 infection at the time of presentation of ROCM (57.54%, p < .0001), moderate to severe COVID-19 (p < .0001), steroid administration (OR 3.63, p < .00001), uncontrolled diabetes (OR 32.83, p < .00001), random blood sugar >178 mg/dl were associated with development of CA-ROCM. Vaccination showed a protective effect (p = .0049). In cases with intracranial or cavernous sinus extension there was history of steroid administration (OR 2.89, p = .024) and orbital apex involvement on imaging (OR 6.202, p = .000037) compared to those with only rhino-orbital disease. CONCLUSION: Male gender, active COVID-19 infection, moderate or severe COVID-19, uncontrolled diabetes, steroid administration during COVID-19 treatment are risk factors for developing rhino-orbital-cerebral mucormycosis. Vaccination is protective. Random blood sugar of >178 mg/dl in COVID-19 positive or recovered patients should warrant close observation and early detection of ROCM. Presence of ophthalmoplegia, blepharoptosis at first clinical presentation and orbital apex involvement on imaging are associated with intracranial extension in ROCM.

Prevalence of Voice Disorders in Indian Female Secondary School Teacher Population-A Cross Sectional Study.

Teachers are the backbone of any civilized society as they are the keepers of knowledge, wisdom and values. Lack of infrastructure, manpower and resources makes voice the most important tool for a teacher. Teachers need to speak loudly for long periods often under unfavourable circumstances. Increased vocal effort and incorrect phonation techniques can lead to vocal fold tissue damage and vocal fold pathologies and hence voice problems producing adverse effects on teaching performance. To study the prevalence of voice disorders in Indian female secondary school teacher population. To identify the risk factors for the development of voice disorders. A multicentric, cross-sectional observational study of 200 teachers were conducted in 4 schools over a period of 2 years. Female teachers who gave consent and were willing for follow up were included in the study. Details were collected using a structured questionnaire. Subjective analysis by VHI, perceptual analysis by GRABS score, acoustic analysis and direct visualization using Hopkins 70° rigid laryngoscope were done.The prevalence of voice disorders was 18.5%. Risk factors identified were age group 41-60 years, repeated respiratory allergies, comorbidities, constitutional symptoms, increased number of years of teaching and number of lecture hours per week. VHI, GRABS, Acoustic analysis findings were consistent with Rigid Laryngoscopic finding making them effective tools in the assessment of voice.

Giant Cell Tumour of Hard Palate and its Surgical Management: Case Report.

The giant cell tumour is a benign but locally aggressive tumour accounting for 5% of all bone tumours typically seen at the metaphyseo-epiphyseal ends of long bones with 1% incidence in skull bones. We are presenting a case report of 40 year old female with GCT of hard palate. An initial pre-operative plan was hard palate removal with complete tumour clearance trans-orally with iatrogenic oro-nasal fistula with rehabilitation to be done with obturator for closure of fistula and dentures to aid chewing. However, intra-operatively the surgical plan was revised and the tumour was removed with preservation of party wall mucosa. Thus, we present this case due to its clinical rarity and academic interest.

Rhino-orbital mucormycosis following COVID-19 in previously non-diabetic, immunocompetent patients.

PURPOSE: To report a series of 13 immunocompetent patients who developed new-onset uncontrolled diabetes mellitus (DM) following COVID-19 infection and presented as rhino-orbital mucormycosis (ROM). METHOD: Retrospective study. RESULTS: A total of 127 patients of COVID-19 Associated Mucormycosis (CAM) were evaluated at four centres in India. All patients underwent endoscopic sinus debridement surgery and received systemic amphotericin-B therapy. Five patients (5/13; 38.4%) received retrobulbar amphotericin-B injections. Orbital exenteration was performed in advanced orbital involvement or progression of orbital disease in spite of maximal medical therapy. In his cohort, 13/127 (10.2%) patients presented with new onset DM, where one patient had bilateral disease. The mean age was 35.9 years (range: 20-51 years) and the mean duration from diagnosis of COVID-19 to the diagnosis of mucormycosis was 14.2 days. While 7/13 (53.8%) of the patients received systemic corticosteroids during the course of their treatment for COVID-19, six patients received no steroids or immunomodulators. The mean follow-up period was 9.2 weeks (range: 3-18 weeks) following discharge. Life salvage was possible in 100% of the cases. While overall globe salvage was possible in 42.8% (6/14 eyes), the globe could be preserved in 4/5 patients who received retrobulbar amphotericin-B injections. CONCLUSIONS: Those involved in the care of COVID-19 patients should be aware about the possibility of recent-onset DM, even in patients without a history of corticosteroid therapy. Rarely, recent-onset DM following COVID-19 may present as rhino-orbital mucormycosis, which requires aggressive surgical and medical intervention.

Clinical Presentations, Management and Outcomes of Rhino-Orbital-Cerebral Mucormycosis (ROCM) Following COVID-19: A Multi-Centric Study.

PURPOSE: To report clinical presentations and factors affecting outcomes in rhino-orbital-cerebral mucormycosis following COVID-19. METHODS: Retrospective multi-centric interventional case series of 58 eyes with rhino-orbital-cerebral mucormycosis. Demography, clinical parameters and management outcomes were noted. Factors affecting outcome and mortality were analyzed. Outcome was defined as favorable when complete resolution or stabilization without further progression of the infection was noted at last visit. RESULTS: Mean age was 55 ± 11 years (median 56). The mean HbA1c value was 10.44 ± 2.84 mg% (median 10.5). The duration between the diagnosis of COVID-19 and rhino-orbital-cerebral mucormycosis was 16 ± 21 days (median: 8 days). Thirty-six eyes (62%) had no vision at presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (41%), cavernous sinus involvement (30%), and central nervous system (CNS) involvement (33%). All the patients were treated with systemic Liposomal amphotericin-B and sinus debridement. Twenty-two eyes (38%) underwent exenteration. One eye underwent transcutaneous retrobulbar amphotericin-B. The mean follow-up duration was 5.62 ± 0.78 months (median 6). Favorable outcome was seen in 35 (60%) cases. Presence of uncontrolled diabetes (p = 0.001), orbital apex involvement (p = 0.04), CNS involvement (p = 0.04), and history of steroid use (p < 0.0001) resulted in unfavorable outcome. CNS involvement was the only factor predicting mortality (p = 0.03). Mortality was seen in 20 (34%) patients. CONCLUSION: Over a third of patients with rhino-orbital-cerebral mucormycosis following COVID-19 have an unfavorable clinical outcome. Uncontrolled diabetes mellitus at presentation, involvement of the orbital apex, CNS, and the usage of steroids were associated with poorer outcomes. CNS involvement was a factor determining mortality.

Role of bronchoscopy and imaging in long-standing foreign body bronchus presenting as recurrent or non-resolving lower respiratory tract infection.

INTRODUCTION: A long-standing retained foreign body in the bronchus is unusual. In majority of cases, an adequate history is not obtained, the clinical picture is usually clouded by superadded pathological changes. CASE SERIES: We report three cases of long-standing foreign body in the airway who presented with recurrent lower respiratory tract infection. Examination of respiratory system revealed no significant abnormality. Chest radiograph was normal. CT scan of the chest was useful to indicate endobronchial opacity in the airway suggestive of a foreign body. The patients underwent rigid bronchoscopy under general anesthesia for successful removal of the foreign body. CONCLUSION: So the patients with non-resolving or recurrent lower respiratory symptoms in spite of medical treatment and without any obstructive findings must undergo diagnostic bronchoscopy evaluation and imaging.

The efficiency of titanium middle ear prosthesis in ossicular chain reconstruction: our experience.

Middle ear ossicular reconstruction is a challenging task for any otologist. Over a period of time, surgeons have tried various types of materials as ossicular prosthesis with varying amount of success. In the last decade, numerous studies have been conducted that have proved that titanium prosthesis is biocompatible. We have conducted this study to investigate the efficiency of titanium middle ear prosthesis (Eon Meditech Pvt. Ltd.) in tympanoplasty. Nineteen patients who underwent tympanoplasty with titanium prosthesis placement from January to October 2010 were included in the study. Fifteen patients underwent reconstruction using titanium PORP while four patients required titanium TORP. The average follow up period was 11.1 months. The pre-operative and post-operative PTAs and the closure of the air-bone gap (ABG) at 0.5, 1, 2, 3 KHz (as per the AAO-HNS guidelines) were analyzed. As per the Indian speech and hearing association (ISHA) guidelines, the patients were classified into groups based on the amount of hearing loss. The improvement in the mean PTA (AC) was 16.21 dB in the PORP group while it was 20.47 dB in the TORP group (P value < 0.05). According to ISHA guidelines, 18 out of 19 (94.8%) patients had either a normal hearing or a mild hearing loss post-operatively. The overall success rate (post-operative ABG ≤ 20 dB) of this series is 68.4%. In this series, there has been no extrusion of the prosthesis. Titanium prosthesis is delicate, easy and quick to handle. They are efficient and suitable implants for middle ear ossicular reconstruction. The use of cartilage between the prosthesis and the graft helps to prevent extrusion of the prosthesis.

Extranodal NK/T cell lymphoma presenting as palatal perforation with oronasal fistula.

A 26 years old female presented with fever, nasal stuffiness with blood stained purulent discharge, nasal twang in voice along with non-healing palatal ulcers since three months. Examination revealed a paramidline perforation in the hard palate causing oronasal fistula formation. Histopathology and immunohistochemistry suggested a diagnosis of extranodal Natural Killer (NK)/T cell lymphoma. Multi-agent chemotherapy was instituted. We report this extremely rare case of Non-Hodgkin's Lymphoma (NHL) of the extranodal NK/T cell variety presenting as palatal perforation.

Radiological correlation between the anterior ethmoidal artery and the supraorbital ethmoid cell.

UNLABELLED: The anterior ethmoidal artery is an important landmark in functional endoscopic sinus surgery. AIMS: We undertook this study to determine the reliability of identification of the artery on the coronal CT scan and to determine whether a correlation exists between the pneumatisation of the suprabullar recess and the vertical distance of the artery from the base skull. MATERIALS AND METHODS: 50 randomly selected CT scans were studied. The anterior ethmoidal artery was identified on each side and the vertical distance between the artery and the base skull was measured. The orbital beak and the superior oblique muscle were used as landmarks to identify the artery. The CT scans were divided into two groups based on whether the supraorbital cell was present or absent. These groups were each further subdivided into 3 groups depending on the vertical distance between the anterior ethmoidal artery and the base skull. RESULTS: The anterior ethmoidal artery was reliably identified in 97% of the cases. When the supraorbital cell was absent, the mean distance between the artery and the base skull was 1.5 mm; while when the cell was present, the mean distance was 4.86 mm. When these groups were evaluated for statistical significance, the p value was 0.000 (highly significant). CONCLUSION: The orbital beak and superior oblique muscle are reliable landmarks to identify the anterior ethmoidal artery. There exists a strong correlation between the vertical distance of the artery from the base skull and the presence of the supraorbital ethmoid cell.

Salvaging vision in an extensive parameningeal rhabdomyosarcoma: A case report.

This communication presents a case report of a parameningeal rhabdomyosarcoma in a young male leading to vision loss which was effectively salvaged using prompt intervention in the form of surgery and high dose systemic steroids. Early debulking was the key in the prevention of complete blindness in our patient.

Virtual bronchoscopy: Our early experience.

Virtual bronchoscopy is one of the many new radiological scanning techniques that have been recently introduced. Virtual endoscopy, according to Ahlquist (Ahlquist and Johnson CD, Gastroenterology, 112, 1997, 2150) is a technique for visualizing interior cavities using computer graphic techniques. Virtual bronchoscopy generates 3D reconstructions of the human airway from high-resolution CT data sets of the chest and performs a simulated bronchoscopy. This method uses perspective surface or volume rendering to produce endoscope-like visualizations of the airway. Our early experience with this new investigative modality in cases of laryngeal and subglottic stenosis and intratracheal tumors is discussed.

Lacrimal sac rhinosporidiosis: a case report.

Rhinosporidiosis is a disease caused by Rhinosporidium seeberi. It usually affects the nasal mucosa and rarely the conjunctiva, lacrimal sac, tonsils, and skin. We present a case study of an isolated lacrimal sac rhinosporidiosis in an 8-year-old girl who was a migrant from Orissa, an Eastern coastal state of India. The mode of presentation and management of this case with a review of literature is discussed in brief.

A foreign body in the pharynx migrating through the internal jugular vein.

We present an unusual and a rare case study of a 45-year-old woman who had swallowed a sharp pointed metallic foreign body while eating meat. The foreign body had migrated from the cricopharynx through the parapharyngeal space and penetrated the internal jugular vein over a period of 10 days presenting as a tender neck swelling. The management of this case is discussed here in brief.