Prevalence of co-existent COVID-19-associated pulmonary aspergillosis (CAPA) and its impact on early mortality in patients with COVID-19-associated pulmonary mucormycosis (CAPM).

BACKGROUND: Data on mixed mould infection with COVID-19-associated pulmonary aspergillosis (CAPA) and COVID-19-associated pulmonary mucormycosis (CAPM) are sparse. OBJECTIVES: To ascertain the prevalence of co-existent CAPA in CAPM (mixed mould infection) and whether mixed mould infection is associated with early mortality (≤7 days of diagnosis). METHODS: We retrospectively analysed the data collected from 25 centres across India on COVID-19-associated mucormycosis. We included only CAPM and excluded subjects with disseminated or rhino-orbital mucormycosis. We defined co-existent CAPA if a respiratory specimen showed septate hyphae on smear, histopathology or culture grew Aspergillus spp. We also compare the demography, predisposing factors, severity of COVID-19, and management of CAPM patients with and without CAPA. Using a case-control design, we assess whether mixed mould infection (primary exposure) were associated with early mortality in CAPM. RESULTS: We included 105 patients with CAPM. The prevalence of mixed mould infection was 20% (21/105). Patients with mixed mould infection experienced early mortality (9/21 [42.9%] vs. 15/84 [17.9%]; p = 0.02) and poorer survival at 6 weeks (7/21 [33.3] vs. 46/77 [59.7%]; p = 0.03) than CAPM alone. On imaging, consolidation was more commonly encountered with mixed mould infections than CAPM. Co-existent CAPA (odds ratio [95% confidence interval], 19.1 [2.62-139.1]) was independently associated with early mortality in CAPM after adjusting for hypoxemia during COVID-19 and other factors. CONCLUSION: Coinfection of CAPA and CAPM was not uncommon in our CAPM patients and portends a worse prognosis. Prospective studies from different countries are required to know the impact of mixed mould infection.

COVID-associated rhinocerebral mucormycosis: a retrospective analysis of presentation and outcomes.

OBJECTIVES: To comprehensively analyse the disease presentation and mortality of COVID-associated rhino-orbito-cerebral mucormycosis. METHODS: A retrospective analysis of the demographics, clinical and radiographic findings was performed. A binary logistic regression analysis was performed to examine the survival of patients with mucormycosis from hypothesised predictors. RESULTS: A total of 202 patients were included in this study. Statistical significance was demonstrated in the predilection to the male gender, recent history of SARS-COV-2, history of use of corticosteroid and hyperglycemia in this cohort of CAM. The mortality rate was 18.31%. Advanced age, raised HbA1c and intra-orbital extension were found to be predictors adversely affecting survival. CONCLUSION: Early diagnosis, aggressive surgical therapy, early and appropriate medical therapy can help improve outcomes. LEVEL OF EVIDENCE: Level 4.

Morphometric Analysis of Temporal Bone Radiology for Cochlear Implant Candidacy.

Cochlear Implantation (CI) is a well-accepted treatment for severe-to-profound sensorineural hearing loss, refractory to conventional hearing amplification. Pre-operative Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) play pivotal roles in patient selection to rule out findings that preclude surgery or identify conditions that may impact the surgical procedure. A prospective study was carried out in a tertiary care center over three years, from January 2020 to January 2023. One hundred and ninety (380 ears) patients' High-Resolution Computed Tomography (HRCT) studies of the temporal bone and MRI scans of the auditory pathways were analyzed. A reporting format was followed which was devised by a team of senior implant surgeons and senior neuro-radiologists. Our study aims to provide a comprehensive radiologic protocol for CI candidacy including normative data for the essential morphometrics in the Indian setting.

Risk factors, mortality, and predictors of survival in COVID-19-associated pulmonary mucormycosis: a multicentre retrospective study from India.

OBJECTIVES: To compare COVID-19-associated pulmonary mucormycosis (CAPM) with COVID-19-associated rhino-orbital mucormycosis (CAROM), ascertain factors associated with CAPM among patients with COVID-19, and identify factors associated with 12-week mortality in CAPM. METHODS: We performed a retrospective multicentre cohort study. All study participants had COVID-19. We enrolled CAPM, CAROM, and COVID-19 subjects without mucormycosis (controls; age-matched). We collected information on demography, predisposing factors, and details of COVID-19 illness. Univariable analysis was used to compare CAPM and CAROM. We used multivariable logistic regression to evaluate factors associated with CAPM (with hypoxemia during COVID-19 as the primary exposure) and at 12-week mortality. RESULTS: We included 1724 cases (CAPM [n = 122], CAROM [n = 1602]) and 3911 controls. Male sex, renal transplantation, multimorbidity, neutrophil-lymphocyte ratio, intensive care admission, and cumulative glucocorticoid dose for COVID-19 were significantly higher in CAPM than in CAROM. On multivariable analysis, COVID-19-related hypoxemia (aOR, 2.384; 95% CI, 1.209-4.700), male sex, rural residence, diabetes mellitus, serum C-reactive protein, glucocorticoid, and zinc use during COVID-19 were independently associated with CAPM. CAPM reported a higher 12-week mortality than CAROM (56 of the 107 [52.3%] vs. 413 of the 1356 [30.5%]; p = 0.0001). Hypoxemia during COVID-19 (aOR [95% CI], 3.70 [1.34-10.25]) and Aspergillus co-infection (aOR [95% CI], 5.40 [1.23-23.64]) were independently associated with mortality in CAPM, whereas surgery was associated with better survival. DISCUSSION: CAPM is a distinct entity with a higher mortality than CAROM. Hypoxemia during COVID-19 illness is associated with CAPM. COVID-19 hypoxemia and Aspergillus co-infection were associated with higher mortality in CAPM.

Correction to: Protocol for Evaluation and Management of Hearing Loss After Meningitis.

[This corrects the article DOI: 10.1007/s12070-022-03277-w.].

Protocol for Evaluation and Management of Hearing Loss After Meningitis.

Bacterial meningitis is the most common cause of post-natal acquired hearing loss in children. Although cochlear implantation helps in improving the hearing in these patients, the fibrosis and ossification of the cochlear lumen that occurs as a result of bacterial meningitis, limits the chances of successful implantation. In developing countries like India, the reduced awareness, limited resources, and financial constraints warrant judicial use of radiological and audiological tests to increase the rate of successful cochlear implantation. The present paper is a review of the literature and a proposed protocol for follow-up of post-meningitis patients to help clinicians diagnose and hence, intervene early when profound hearing loss occurs. Every patient who has had an episode of bacterial meningitis must be followed up for atleast 2 years for possible hearing loss with frequent audiological and radiological evaluation, as required. Cochlear implantation must be done as early as possible when profound hearing loss is detected.

Evolving Essential and Desirable Requisites for Clinical Fellowship in Cochlear Implant Surgery.

Studies from developed countries show the prevalence of permanent childhood hearing loss to be 1 to 2 per thousand children. The estimated number of Ear, Nose, and Throat (ENT) specialists and otologists in India were 7000 and 2000. There is a great need for trained CI surgeons to care for that burden. Currently, only a handful of centres in the country provide CI training. This study aims to put together essential and desirable requisites for a clinical fellowship in CI surgery for ENT surgeons. A questionnaire was prepared and validated by 25 senior CI surgeons in India. Then the sixteen-question questionnaire was prepared and administered to 100 practising CI Surgeons (Group A) and 100 probable CI Fellowship Candidates (Group B). Group B involved surgeons currently pursuing their ENT post-graduation or have completed their postgraduate training and are inclined towards otology and CI surgery in the future. The responses ranged from 1 (Strongly Disagree) to 5 (Strongly Agree) on a Likert Scale. The responses from both groups were analyzed, and statistical analysis was performed using SPSS(Statistical Package for the Social Sciences) software. The results were analysed and tabulated from both groups. The weighted mean response and mean opinion to all the questions were calculated for both groups. Based on the response, "Essential" and "Desirable" criteria are given.

Diagnostic Positional Tests and Therapeutic Maneuvers in the Management of Benign Paroxysmal Positional Vertigo.

Benign Paroxysmal Positional Vertigo (BPPV), the most common vestibular disorder characterized by recurrent, brief episodes of vertigo, is attributed to the presence of otoconia in the semicircular canals. Two mechanisms contribute to its cause-canalolithiasis (otoconia freely mobile in the semicircular canal) and cupulolithiasis (otoconia adherent to the cupula). Posterior semicircular canal is the most common canal involved. Although the occurrence of BPPV in lateral and superior semicircular canal is rare, with the advancement in diagnostic techniques, their incidence is being reported in the past few years. Various diagnostic tests and therapeutic maneuvers have been described in the management of BPPV. The present report is a comprehensive review of the tests and maneuvers for BPPV written as a guide intended to help the clinicians in the accurate diagnosis and application of a canal-specific treatment maneuver for BPPV. A simplified algorithmic approach ("The Bangalore BPPV Algorithm") for the management of BPPV is described.

Evolving a Radiological Protocol for Cochlear Duct Length Measurement: Three Audit Cycles.

To develop an accurate protocol for measuring the Cochlear Duct Length (CDL) by using Multi Detector Computerized Tomography (MDCT) imaging of the temporal bones and thereby make the appropriate choice of electrode for cochlear implantation. 79 MED-EL® Cochlear implantees were divided into three cohorts in chronological order of their implantation. CDL was calculated from MDCT images and correlated with the CDL calculated using the existing Jolly's formula. Results of the CDL measured by unfurling the cochlea correlated well with the existing formula. In addition to CDL measurement, measuring diameter of each turn, especially the apical turn, helped in choosing the appropriate electrode for complete cochlear coverage. Having dedicated radiographers and neuro-radiologists can avoid inter-observer variations in CDL measurements. Measuring the CDL and the diameter of each turn helps in choosing an appropriate electrode thus minimizing intra-operative difficulties and achieving complete safe insertion.

Cochlear Implant in a Child with a Large Arachnoid Cyst and Cysto-peritoneal Shunt.

Profound hearing loss requiring cochlear implantation and arachnoid cyst requiring placement of Cysto-Peritoneal Shunt (CPS) are two commonly seen entities. However, there are very few published cases of patients requiring both of them. The present report describes the importance of multidisciplinary surgical planning in one such patient.

Intra-ductal Foreign Body (Fish Bone Fragment) as a Cause of Obstructive Sialadenitis: A Case Report.

Submandibular sialadenitis is a common ailment in otorhinolaryngological and oral surgical practice. Some of the common causes of sialadenitis include sialolithiasis, inspissated mucous plugs, strictures and anatomical ductal variations. Very rarely do foreign bodies cause obstructive sialadenitis. Fish bone as a foreign body is routinely seen, with the most common locations being oropharynx, hypopharynx, oseophagus and tongue. We report an intriguing case of a 40 year old male with sialadenitis of the right submandibular gland due to an intra-ductal fish bone.

Neurofibromatosis 2: Primary Modality of Hearing Rehabilitation with Cochlear Implant.

Auditory Brainstem Implants have been recommended as the gold standard in hearing rehabilitation of Neurofibromatosis Type 2 patients who lose hearing completely in both the ears and the cochlear nerves are not stimulable. Some patients have undergone cochlear implantation, in whom the cochlear nerve was spared during surgery or have undergone stereotactic radiotherapy preserving the function of the cochlear nerve. Here we report a case in whom we chose cochlear implantation prior to any definitive treatment for the tumour itself during the 'wait and watch' period. The reasons in favour of this approach have been discussed in this article. Post switch-on the implant is benefitting the patient satisfactorily and she is on regular follow up for monitoring the bilateral tumours.

Bilateral Bone Anchored Hearing aids: A Case Report on Right Side Percutaneous and Left Side Transcutaneous Implant.

Bilateral Bone Anchored Hearing Aids (BAHA) provide more subjective patient satisfaction and outcome than unilateral BAHA. Initially, percutaneous BAHAs were used for many decades. Transcutaneous BAHAs were started later to overcome problems associated with percutaneous ones. The present report gives the outcome of bilateral BAHA in a patient with percutaneous BAHA on one side and transcutaneous BAHA on the other.

Endoscopic Removal of Intranasal Supernumerary Tooth: A Case Report.

The presence of an ectopic tooth into the nasal cavity is unusual. It can be supernumerary, deciduous or permanent. It is important to identify it early to prevent complications such as epistaxis, paranasal sinusitis, nasal septal deviation, nasal septal abscess, and oral-nasal fistula. The diagnosis of nasal teeth is mainly based on clinical and radiographic examination. Treatment is early extraction and endoscopy gives good illumination and helps in easy and precise dissection which is better than old morbid traditional techniques. We report a case of a female presenting with nasal obstruction and foul smell, diagnosed with nasal tooth and successfully removed with endoscopic approach.

The common cavity vs incomplete partition type I conundrum: Decision making and management with the cochlear implant form electrode.

It has been seen that 20% of children with deafness have inner ear malformations. Studies demonstrate that Cerebrospinal Fluid (CSF) leakage occurs in 40-50% of patients with inner ear malformations. Differentiating between the various malformations pre-operatively allows the cochlear implant surgeon to plan and prepare for various difficulties associated with the management of such cases. In case of a CSF gusher, a choice of an electrode with a stopper helps in effectively closing off the cochleostomy, thus reducing the chances of post-operative infections. Case description: SM, a 10-year-old girl with the diagnosis of bilateral progressive profound hearing loss showed cochlear malformations on high resolution computed tomography (HRCT) scans of the temporal bones. A detailed study and discussion with the neuro-radiologist helped in identifying the cochleo-vestibular malformations (CVM) on both sides, thus making the choice of the better ear for electrode insertion and the type of electrode. She was subjected to left ear cochlear implantation using a lateral canal labyrinthotomy approach and a Form electrode (Med El®) with a special conical stopper was used to effectively seal the labyrinthostomy. Conclusion: Common cavity (CC) and Incomplete Partition (IP) Type I present as diagnostic challenges. Getting to the right diagnosis is of paramount importance as it helps in deciding the correct ear, choosing the correct electrode, and preparing for the surgical situations the surgeon might encounter. The Form electrode shows promise due to its unique conical seal which helps in preventing CSF leakage, thus reducing the chances of post-operative infections in cases of deformed cochlea.

Cochlear Implantation in a Patient with Failed Renal Transplant: A Case Report.

Cochlear implantation has become a standard tool of management of severe to profound hearing loss. Cochlear implantation in patients with chronic renal failure who are on hemodialysis are at greater risk of complications intraoperatively and postoperatively. Very few cases of cochlear implantation have been reported in the English literature so far following renal transplantation. Herein we report a case of cochlear implantation in a 37 year old lady with post renal transplant failure who is on maintenance hemodialysis.

A questionnaire-based analysis of parental perspectives on pediatric cochlear implant (CI) re/habilitation services: a pilot study from a developing CI service in India.

OBJECTIVE: To study parental perspectives on re/habilitation services offered for pediatric cochlear implant (CI) users at a non-profit organization in India. METHODOLOGY: A non-standardized questionnaire comprising 46 items was created to understand perspectives of parents of pediatric CI users. Questions were designed to examine re/habilitation services from the angles of service delivery, parental stress levels, reasons for delay in obtaining services, sources of emotional support, concerns, and fears during each stage starting from diagnosis of hearing loss to CI surgery, re/habilitation services and parents' views of their children post-CI. The questionnaire was posed to 30 parents and responses were recorded and coded. RESULTS AND DISCUSSION: Qualitative and quantitative analyses based on parents' responses identified several factors that significantly influenced parental perspectives during each stage. The major factors delaying the decision to go for CI included a fear of surgery, lack of funds for CI and the subsequent re/habilitation process, and limited knowledge. Key concerns were the child's academic performance and social acceptance. Familial support played an important role during each stage. A significant reduction in the parental stress levels was observed following CI surgery. Parents indicated that local support for therapy, financial assistance and better guidance at each stage would substantially help in lowering stress levels. CONCLUSIONS: The parental perspectives analyzed in this study can be utilized towards improving the quality of service delivery in terms of parental satisfaction and outcomes post-CI. Efforts should be taken to improve parental awareness, funding options, and access to re/habilitation services and social networks connecting similar parents.

The aetiology and management of atrophic rhinitis.

Atrophic rhinitis is a chronic, debilitating and recalcitrant disease of the nasal cavities that is prevalent in several parts of the world. It has unique epidemiological features and clinical characteristics. Clinicians and researchers for decades have tried to postulate theories for the aetiology of the primary form of the disease. Management of the disease has seen several medical therapeutic regimens including alternative forms of medicine. Surgical options for the condition are also not completely satisfactory with a number of failures and recurrences. The authors provide here a comprehensive review of the existing literature as regards the aetiology and management of this refractory condition.