Loosening of Teeth, an Unusual Presentation of Mucormycosis in COVID-19 Infected Patients.

Aim of our study was to report unusual presentation of mucormycosis in patients, who were recovered from COVID-19 infection. This was a prospective observational study, undertaken at Ravindra Nath Tagore Medical College, Udaipur, India, over a period of last 3 months (April-June 2021). All patients with maxillofacial and dental mucormycosis were included in the study. All patients either have COVID-19 infection or recovered from it. Eight (40%) patients had history of use of corticosteroids for COVID1-19 infection, fifteen patients had either known case of diabetes or newly diagnosed diabetes with uncontrolled blood sugar at the time of presentation, three (15%) patients were in pre-diabetic state with HbA1c between 6.0 and 6.5% and two patients had no diabetes. None of patients had diabetic ketoacidosis and only one patient reported complete loss of vision with dental symptoms. There was unusual presentation of mucormycosis in form of loosening of teeth in uncontrolled diabetes. Injudicious use of steroids and uncontrolled diabetes are two main risk factors, so eyes should be kept on both of these.

A Cross-Sectional Study of First Hundred Cases of Rhino-Orbital-Cerebral Mucormycosis Admitted at a Tertiary Care Hospital.

Background: With the second wave of coronavirus disease (COVID-19) Rhino Orbito Cerebral Mucormycosis (ROCM) has emerged as an epidemic in India. Early suspicion and management can reduce disfigurement and mortality. Objectives: To identify the demographic and clinical profile of ROCM, its association with COVID-19 and other predisposing factors. Methods: Hospital Based Cross Sectional Observational study on first hundred consecutive patients with signs and symptoms and radiological findings suggestive of ROCM. Data collected from patient records and analyzed. Results: Out of hundred, 72 patients were Males, 74 from rural areas, all were above eighteen years age, 35 presented with orbital and 27 with facial manifestations of ROCM. Main predisposing factors were history of COVID-19 (71%), previous hospitalization (48%), in Intensive Care Unit (5%) systemic corticosteroid therapy (48%), Diabetes, uncontrolled (45%) and new (21%). Conclusions: ROCM presented with orbital and facial manifestations. Main predisposing factors were Diabetes, COVID-19 and systemic steroids.

Correlation Between Anosmia and Severity Along with Requirement of Tocilizumab in COVID-19 Patients.

Anosmia with or without dysgeusia is frequently associated with Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) SARS-CoV-2 infection. SARS-CoV-2 virus affects the olfactory system and thus represents neurotropic and neuro-invasive nature of the virus. We found that tocilizumab's role in reducing mortality in severe covid-19 infection is still questionable and aim of our study was correlation of anosmia and severity of covid-19 infection and requirement of tocilizumab in anosmia patients. To establish relationship between anosmia and severity of COVID-19 infection along with requirement of tocilizumab. This was a retrospective cum prospective cross sectional study done on COVID-19 patients who were admitted in normal COVID-19 ward and intensive care unit of Employee's State Insurance Corporation Hospital, Udaipur and Maharaja Bhupal Hospital of Ravindra Nath Medical College between September 2020 and 15 January 2021 age group of 18 to 92 years, both sexes. We had asked about anosmia in all COVID-19 positive patients and followed all patients in perspective of severity of disease and tocilizumab. p value < 0.001 of prevalence of anosmia in COVID -19 patients who were isolated at home, admitted in ward and intensive care unit showed that anosmia is inversely related to severity of disease. Tocilizumab has no significant role in decreasing mortality in severe form of disease. Our study indicates that anosmia is related to the mildness of disease and there is no role of tocilizumab in decreasing the mortality in severe form of disease.

A multicenter observational study on the role of comorbidities in the recurrent episodes of benign paroxysmal positional vertigo.

OBJECTIVE: Primary objective of this study was to find a statistical link between the most worldwide comorbidities affecting the elderly population (hypertension, diabetes, osteoarthrosis, osteoporosis and depression) and recurrent episodes of BPPV. Secondary objective was defining possible "groups of risk" for people suffering recurrent positional vertigo related to the presence of a well documented comorbidity. METHODS: This was an observational, cross-sectional, multicenter, spontaneous, non-pharmacological study. The data of 1092 patients suffering BPPV evaluated in 11 different Departments of Otolaryngology, Otoneurology and Neurology, referring Centers for positional vertigo evaluation, were retrospectively collected. RESULTS: Regarding evaluated comorbidities (hypertension, diabetes, osteoarthrosis, osteoporosis and depression), data analysis showed the presence of at least one comorbid disorder in 216 subjects (19.8%) and 2 or more in 408 subjects (37.4%). Moreover there was a statistical significant difference between the number of comorbidities and the number of recurrences, otherwise said as comorbidity disorders increased the number of relapses increased too. CONCLUSION: The presence of a systemic disease may worsen the status of the posterior labyrinth causing a more frequent otolith detachment. This condition increases the risk for patients suffering BPPV to have recurrent episodes, even if correctly managed by repositioning maneuvers. The combination of two or more of aforementioned comorbidities further increases the risk of relapsing BPPV, worsened by the presence of osteoporosis. On the basis of this results it was possible to define "groups of risk" useful for predicting BPPV recurrence in patients with one or more comorbidity.

Are postural restrictions necessary for management of posterior canal benign paroxysmal positional vertigo?

OBJECTIVES: An important component of management of benign paroxysmal positional vertigo (BPPV) has been the application of postural restrictions after use of a canalith repositioning maneuver (CRM) to prevent the return of otolithic debris into the posterior semicircular canal (PSC). This study was designed to explore the effectiveness of postural restrictions in patients with BPPV caused by otolithic debris in the PSC. METHODS: Seventy-four adult patients with unilateral PSC BPPV were enrolled into this study. All patients were managed with a CRM--either the modified Epley maneuver or the Semont maneuver. The patients were divided randomly into 2 groups: group A, with postural restrictions, and group B, without postural restrictions. The statistical analysis was performed with X2 tests and t-tests. RESULTS: No patients in either group showed positional nystagmus in the posttreatment evaluation under infrared videonystagmoscopy. No patients had symptoms of vertigo after the therapy. The results of follow-up vestibular tests were normal in both groups. CONCLUSIONS: In our experience, postural restrictions do not enhance the beneficial effect of the CRMs. They do not seem to have any protective role and therefore should not be recommended as an adjunct to the treatment of PSC BPPV.

Treatment of sudden sensorineural hearing loss with transtympanic injection of steroids as single therapy: a randomized clinical study.

The aim of this study was to verify the efficacy and the safety of transtympanic dexamethasone to treat sudden sensorineural hearing loss as first and single drug method. Considering ethical implication of performing a mininvasive procedure on middle ear, we matched such proposed treatment with systemic prednisone administration that represents the widest adopted protocol. Randomized prospective study was conducted. The inclusion criterion was a sudden sensorineural hearing loss of at least 30 dB across three contiguous frequencies over a period of 24 h. Group A received transtympanic steroid injections; Group B received oral administration of steroids. 25 patients were treated with transtympanic therapy whereas 21 underwent systemic treatment. The mean of initial PTA was 59 dB for the whole series: 65 dB for group A and 51 dB for group B. The recovery better than 10 dB was obtained in 80% of patients of group A and in 17 81% of patients of group B, with a total of 80.5%. The mean relative gain in PTA was 41.16% in the group A and 44.7% in the group B. In the frequencies tested (0.5, 1, 2, and 4 kHz) PTA improvements after transtympanic treatment were higher than after systemic treatment, but these differences were not statistically significant (P = 0.61). Both transtympanic and systemic treatment had similar clinical recovery times. This prospective randomized clinical study showed good result in terms of hearing recovery, better than the expected results of the simple observation without treatment. We can consider transtympanic administration as a first line treatment, because of the statistical analysis confirmed similar results with systemic therapy, reducing possible side effects of systemic drug administration. The delay of treatment does not influence the outcome, allowing treating patients within 10 days of onset.

Benign paroxysmal positional vertigo following whiplash injury: a myth or a reality?

OBJECTIVE: The aim of the study was to evaluate the true incidence, diagnosis, and treatment of benign paroxysmal positional vertigo (BPPV) arising after whiplash injury and to distinguish this type of posttraumatic vertigo from other types of dizziness complained after trauma. METHODS: This was a retrospective study comprising patients referred to our center after whiplash injury. The patients were evaluated with neurotologic examination including bedside and instrumental tests. A Dizziness Handicap Inventory evaluating the symptoms of patients was submitted before and after treatment and was evaluated. The BPPV patients were separately evaluated from those with cervicogenic vertigo, and a comparison between our data about idiopathic BPPV was done. RESULTS: Eighteen patients of whiplash who had BPPV were evaluated. The mean age was 38.2 years. BPPV was the cause of vertigo in 33.9% of total whiplash patients. In 16 cases, the posterior semicircular canal was involved; the lateral semicircular canal was involved in 2 cases. The instrumental neurotologic assessment did not show any alteration of either vestibulospinal reflexes or dynamic ocular movements. Duration of symptoms before treatment ranged from 3 to 26 days. A total of 55.5% of patients had relief from their symptoms after first repositioning maneuver. The Dizziness Handicap Inventory score improved in all patients treated with repositioning maneuvers, but no difference emerged with idiopathic BPPV data. CONCLUSION: BPPV after whiplash injury could be unveiled with a simple bedside examination of peripheral vestibular system, and a treatment could be done in the same session. The diagnosis of posttraumatic BPPV is not different from the idiopathic form, but the treatment may require more maneuvers to achieve satisfactory results.

Analysis of visually guided eye movements in subjects after whiplash injury.

OBJECTIVE: The aims of present research were to analyze the visually guided eye movements of subjects suffering from the consequences of whiplash injury and the possibility to differentiate patients from feigning subject. We analyzed the role of video-nystagmography for clinical and forensic aspects. METHODS: It was a prospective case-control study. Detailed history was taken and patients were thoroughly investigated. Smooth pursuit and saccadic eye movements were assessed in 33 patients affected by imbalance following a whiplash injury. A control group of 20 subjects was also evaluated. All tests were executed in neutral neck position and after left and right trunk rotation. RESULTS: The t-test, applied to all parameters showed that difference of the parameter between the groups was not statistically significant. CONCLUSION: The visually guided eye movement evaluation does not seem to offer a clinically relevant method to differentiate patients suffering from the effects of whiplash injury from normal subjects.

Modified fronto-lateral laryngectomy in treatment of glottic T1(a-b) cancer with anterior commissure involvement.

OBJECTIVE: Evaluation of clinical and oncological safety of the modified fronto-lateral laryngectomy in the treatment of T1a-b glottic cancer. METHODS: Retrospective review of charts of patients managed with classical fronto-lateral laryngectomy or with our modified technique using a cervical fascia flap and a false cord flap to reconstruct the defect. RESULTS: No recurrence of cancer was observed in the present series and slight dysphonia was present in all cases. The patients managed with classical technique required a revision surgery for granulations or anterior synechia in 4 cases; those managed with modified technique did not need a second intervention. CONCLUSION: The fronto-lateral laryngectomy should be present in the head-neck surgeon armamentarium. In T1a-b glottic cancer this technique gives a good oncological resection, but the postoperative period requires an intensive rehabilitation process. The modification of the classical technique reduces the incidence of a second intervention.

Otoneurological management of petrous apex cholesterol granuloma.

OBJECTIVE: The aim of the study is to review the management of petrous apex cholesterol granuloma. The surgical approaches for drainage or total removal and the wait and see policy were analyzed, and outcomes were evaluated. METHODS: Retrospective charts of 27 patients managed for petrous apex cholesterol granuloma with a minimum follow-up of 12 months were analyzed in a quartenary skull base center. Presenting symptoms and signs were recorded, and radiologic imaging was evaluated. Management options included wait and see policy and surgery by several approaches. RESULTS: The mean age of patients affected by the lesion was 38.8 years. The mean follow-up was 56.7 months. Patients complained of hearing loss, vertigo, tinnitus, diplopia, hemifacial spasm, trigeminal neuralgia, and facial paresthesia. Twelve patients were managed by wait and see policy, and in this category, only one lesion showed growth during the follow-up. Depending upon size and location, 15 patients were surgically treated by infralabyrinthine approach (9 patients), infratemporal type B approach (3 patients), combined infratemporal type B transotic approach (2 patients), and transotic approach (1 patient). One recurrence was recorded during the follow-up. CONCLUSIONS: Radiologic evaluation is required for diagnosis and management. Patients with good hearing can be treated by infralabyrinthine approach. Infratemporal fossa type B approach is advocated in patients with extensive disease and internal carotid artery involvement. Wait and see policy is recommended for asymptomatic cases. Drainage and permanent ventilation are the goals of treatment. Complete removal is indicated in selected cases where placement of drainage tube is not feasible.

Squamous cell carcinoma of the superior gingival-buccal complex.

Squamous cell carcinoma of the superior gingival-buccal complex are rare and few English-language data have been published on their biological behaviour. Reported in this paper are the clinical behaviour and treatment outcomes of squamous cell carcinoma of the upper gingival-buccal complex. We reviewed the charts of 110 patients with squamous cell carcinoma restricted to the upper gingiva, superior gingival-buccal sulcus and adjoining buccal mucosa, seen between 1997 and 2001. Separate outcome analyses were carried out among 86 patients who had undergone surgery, and 24 patients treated by radiotherapy or chemo-radiation. Disease-free survival at 2 and 5 years was 48.9% and 36%, respectively, and was independent of epicentre of disease. Five-year, disease-free survival was 48.8% and 0% for surgical treatment and non-surgical treatment groups. T stage (p=0.024) and extra-capsular spread of disease (p=0.036) were independent predictors of disease-free survival on multivariate analysis. Adequate surgical resection and adjuvant treatment, in the first instance, offers the best chance of disease control.

Buccal plate excision for buccal paramandibular spread.

Cancer of buccal gingival sulcus lie in close proximity to mandible but tend to invade bone late in the course of disease. Segmental mandibulectomy advocated for these tumors results in cosmetic disfigurement and functional impairment. We, for the first time, describe a mandibular preservation alternative, in form of buccal cortical plate excision, for these tumors.