Covid-19-associated rhino-orbito-cerebral mucormycosis (CAROM) in Delhi: Demographics and risk factors in a single-centre consecutive cohort of 200 inpatients

BACKGROUND There was a dramatic rise in the incidence of rhino-orbito-cerebral mucormycosis associated with the 2021 Covid-19 wave in India. We aim to document the demographic characteristics and risk factors of a consecutive cohort of inpatients with Covid-19-associated rhino-orbito-cerebral mucormycosis (CAROM) during the surge of April–June 2021. METHODS We included all patients of CAROM treated at our tertiary referral facility from 1 April to 14 June 2021. We prospectively gathered details with regard to Covid-19 illness and treatment, CAROM presentation, comorbid conditions and risk factors. RESULTS Our prospective cohort consisted of 200 consecutive patients, of which 146 (73%) patients tested positive on the Covid-19 RT-PCR test at presentation. CAROM occurred concurrent with the Covid-19 infection in 86%, and delayed CAROM after seeming recovery from Covid-19 was seen in 14%. Covid-19 was classified as mild, moderate and severe in 54%, 33% and 13%. The surge of CAROM followed the population peak of Covid-19 infections by about 3 weeks. Advanced disease at presentation was frequent with ocular involvement in 56.6% (111/196) and central nervous system involvement in 20% (40/199). One or more comorbid conditions were identified in 191/200 (95.5%) patients. The dominant associations were with diabetes (189/200; 94.5%) and uncontrolled hyper-glycaemia (122/133; 91.7%), recent steroid use (114/ 200; 57%), which was often considered as inappropriate in dosage or duration, lymphopenia (142/176; 80.7%), and increased ferritin levels (140/160; 87.5%). No evidence supported the role of previous oxygen therapy or previous nasal swab testing as risk factors for CAROM. CONCLUSION The inpatient volumes of CAROM were noted to parallel the Covid-19 incidence curve by about 3 weeks. Covid-19 infection may directly predispose to CAROM by way of lymphopenia and increased ferritin levels. Uncontrolled hyperglycaemia is identified as a near-invariable association. Recent steroid use is noted as very frequent and was often received in excess of treatment advisories.

Prevalence of hearing loss in India

BACKGROUND Despite abundant literature, a clear and coherent understanding of hearing loss (HL) in India is limited by the wide disparity in studies. METHODS We did a review of published peer-reviewed journal articles. Studies reporting the prevalence and degree of HL in India from 1980 to 2020 were included. Information was gathered on the population characteristics, methodology applied and the prevalence of hearing impairment. The data were analysed to identify trends and at-risk sections of population in various categories. RESULTS Four hundred and forty studies were identified after a database search; 29 full-length articles were selected for final analysis. Using a 3-step screening protocol, hearing impairment (abnormal auditory brainstem response/auditory steady state response) in neonates ranged between 1.59 and 8.8 per 1000 births. Among ‘at risk’ neonates, it ranged from 7 to 49.18 per 1000 births. In children the prevalence of HL was 6.6% to 16.47%. Otitis media was the most common cause of HL in children. Community-based studies (all ages) reported prevalence of HL between 6% and 26.9% and prevalence of disabling HL between 4.5% and 18.3%. Rural areas and elderly showed a higher prevalence of hearing impairment. CONCLUSION Despite India’s improving health indices, hearing disability remains persistently high. It is a major contributor to the loss of personal potential and a financial strain for the individual and the country. A large-scale multicentric study to identify the degree and type of HL, social awareness campaigns, widespread neonatal screening, strengthening treatment facilities and well-funded rehabilitation programmes can counter the rising prevalence of hearing impairment.

Ultrasonography guided fine needle aspiration cytology in patients with laryngo-hypopharyngeal lesions / Punção aspirativa por agulha fina guiada por ultrassonografia em pacientes com lesões laríngeo-hipofaríngeas

Abstract Introduction: Laryngeal lesions are usually evaluated by microlaryngoscopy/direct laryngoscopy under anaesthesia for disease mapping and tissue diagnosis. However patients with anticipated airway compromise due to laryngeal mass may require either a protective tracheotomy or emergency tracheotomy to secure the airway. To minimise risk of unplanned tracheotomy and expedite the diagnosis we performed ultrasound-guided transcutaneous fine needle aspiration cytology. Objective: To evaluate the feasibility and performance of ultrasound-guided transcutaneous fine needle aspiration cytology of suspicious/recurrent laryngo-hypopharyngeal masses. Methods: Fine needle aspiration cytology was performed under ultrasound guidance. Twenty- four patients were recruited, of which 17 had a pure laryngeal lesion; 6 patients had laryngo-pharyngeal, and one patient had a base tongue lesion with supra-glottis extension. Results: Out of 24 patients, 21 had positive cytology for squamous cell carcinoma, 2 patients had non-diagnostic cytology (atypical cells) and the other had inadequate tissue for definitive diagnosis. Patients with negative and inconclusive cytology underwent direct laryngoscopy biopsy, which was positive for squamous malignancy. All patients tolerated the procedure well and no adverse events were noted. Conclusion: Although direct laryngoscopy remains the standard of care in evaluation of laryngo-hypopharyngeal lesions, this pilot study has shown that ultrasound-guided transcutaneous fine needle aspiration cytology was feasible as an out-patient procedure, employing safe and sensitive technique enabling rapid diagnosis and avoiding the need for direct laryngoscopy under GA for tissue diagnosis.

Resumo Introdução: As lesões laríngeas são geralmente avaliadas por microlaringoscopia/laringoscopia direta sob anestesia para mapeamento da doença e diagnóstico tecidual. No entanto, em pacientes com comprometimento prévio das vias aéreas devido à lesão laríngea, pode ser necessária uma traqueostomia protetora ou traqueostomia de emergência para assegurar as vias aéreas. Para minimizar o risco de uma traqueostomia não planejada e facilitar o diagnóstico, realizamos punção aspirativa por agulha fina guiada por ultrassonografia transcutânea. Objetivo: Avaliar a viabilidade e o desempenho da punção aspirativa por agulha fina guiada por ultrassonografia transcutânea em lesões laríngeo-hipofaríngeas suspeitas/recorrentes. Método: A punção aspirativa por agulha fina foi realizada sob orientação ultrassonográfica. Foram recrutados 24 pacientes, 17 com lesão laríngea apenas, 6 com lesão laríngeo-faríngea e um com lesão na base da língua com extensão supraglótica. Resultados: Dos 24 pacientes, 21 apresentaram citologia positiva para carcinoma espinocelular, 2 citologia não diagnóstica (células atípicas) e o outro tecido inadequado para o diagnóstico definitivo. Os pacientes com citologia negativa e inconclusiva foram submetidos à biópsia através de laringoscopia direta, que foi positiva para lesão maligna espinocelular. Todos os pacientes toleraram bem o procedimento e nenhum evento adverso foi observado. Conclusão: Embora a laringoscopia direta continue a ser o padrão de cuidado na avaliação das lesões laríngeo-hipofaríngeas, este estudo piloto demonstrou que a punção aspirativa por agulha fina guiada por ultrassonografia transcutânea é uma técnica viável, ambulatorial, segura e sensível, permite rápido diagnóstico e evita a necessidade de laringoscopia direta sob anestesia geral para diagnóstico tecidual.

Study of Sigmoid Sinus Variations in the Temporal Bone by Micro Dissection and its Classification - A Cadaveric Study

Abstract Introduction Sigmoid sinus (SS) variations have been classified variously in the literature. These classifications suffer from some form of shortcoming from a clinical point of view for their application. Objective We propose a clinically relevant classification of the SS in relation to the posterior semicircular canal (PSCC) and to the exposure of the presigmoid dural plate. The positioning of the SS was analyzed with reference to the volume of themastoid and to the level of mastoid pneumatization. Methods A total of 94 formalin-preserved human cadaveric temporal bones were microdissected to carry out a complete mastoidectomy. The SS, the presigmoid dural plate, and the PSCCwere exposed, and the position of the former was analyzed in relation to the latter two in order to classify the position of the SS into three grades. Results GradeI hadthebest exposureof the presigmoid dura andof the PSCC,while grade III had the poorest exposure of the presigmoid dura and of the PSCC. Grade I SS was associated with good pneumatization and highermastoid volumescompared with grades II and III. Conclusions The SS exhibits considerable anatomic variability. A favorable positioning of the SS is associated with a large mastoid volume and pneumatization. A careful preoperative study of the imaging may help in understanding the positioning of the SS and the safety of various transmastoid approaches.

Role of narrow band imaging in the diagnosis of laryngeal lesions: Pilot study from India

INTRODUCTION: Narrow band imaging (NBI) is a new imaging technique developed to improve the diagnostic accuracy of head and neck cancers by depiction of tumor-specific neo-angiogenesis. The purpose of this study was to assess the value of NBI in the diagnosis of laryngeal lesions. AIM: To assess the sensitivity and specificity of combined white light endoscopy (WLE) and NBI compared with WLE alone in the diagnosis of laryngeal lesions. SETTINGS AND DESIGN: Prospective study. MATERIALS AND METHODS: Thirty consecutive patients with various laryngeal lesions scheduled for microlaryngoscopic evaluation underwent WLE followed by NBI. Endoscopic NBI findings were classified into five types (I–V) according to the intraepithelial papillary capillary loop features. Types I–IV are considered benign, whereas type V is considered malignant. The observations were compared with histopathology. STATISTICAL ANALYSIS: Sensitivity, specificity, and positive and negative predictive values for the diagnosis of malignancy (i.e., invasive carcinoma and carcinoma in situ) by means of NBI with WLE were calculated. RESULTS: The sensitivity of WLE combined with NBI (100%) was higher than WLE alone (82.6%) in detecting laryngeal cancers. NBI helped in identifying four malignant lesions missed by WLE alone. Two children with respiratory papillomatosis also demonstrated type V pattern, a potential pitfall, leading to an overall positive predictive value of 92% and a negative predictive value of 100%. CONCLUSION: Combining NBI with WLE increases the sensitivity of detection of laryngeal cancer and its precursor lesions. NBI is also useful in some benign lesions as well as in post-radiotherapy patients.

Large lipid-rich mammary analogue secretory carcinoma of parotid gland: An unusual case.

Mammary analogue secretory carcinoma (MASC) of the salivary gland is a malignant tumor which bears morphologic, immunohistochemical and molecular features similar to those of mammary secretory carcinoma. The tumor is considered as a low-grade malignancy perhaps slightly more aggressive than acinic cell carcinoma. High-grade transformation with recurrences, regional nodal involvement, metastases, and cancer-related death has been reported in a few cases. We report an unusual case of large MASC of the parotid gland in a young patient without regional lymph node involvement. To the best of our knowledge till date such a large MASC of the salivary gland has not been reported in the English literature.

Morgagni Stewart Morel syndrome--additional features.

A case of Morgagni Stewart Morel syndrome with progressive depression in frontal bone, headache, transient monoparesis, obesity; imbalance, neuropsychiatric symptoms and recurrent disc prolapse with absent right radial pulse is discussed. This syndrome was first mentioned 235 years back, but till now exact pathology is not known. Balance assessment using dynamic posturography was done, which revealed abnormal vestibular function. To our knowledge this is the first case examined for Dynamic Posturography.

Endoscopic correction of severe laryngomalacia.

Tracheostomy for management of severe laryngomalacia is associated with significant morbidity and mortality. Two cases are reported wherein the laryngeal abnormality was corrected by ary-epiglottic fold incision and CO2 laser supraglottoplasty. Stridor and respiratory obstruction were relieved and a long term tracheostomy avoided. Endoscopic correction of laryngomalacia offers significant benefits over conventional treatment with tracheostomy in terms of decreased morbidity and improved quality of life.

Partial maxillectomy for malignant neoplasms of para nasal sinuses and hard palate.

BACKGROUND: The universal application of sectional imaging to the evaluation of para nasal sinus neoplasms has indicated that many of the regions encompassed in a total maxillectomy are often uninvolved and are perhaps unnecessarily resected. METHODS: A set of guidelines was formulated regarding the indications and techniques of partial maxillectomies. These guidelines were then tested on a prospective cohort of 20 cases. The adequacy was judged by histological evaluation of all resection margins. Morbidity was assessed in terms of functional parameters (trismus, swallowing disturbances, speech disturbances) and cosmetic parameters (cheek retraction). RESULTS: As per the pre-formulated guidelines a partial maxillectomy (PM) was suitable in ten and was undertaken. The same was unsuitable in the other ten and these therefore had a total maxillectomy (TM). Four of ten cases in each group had an involved resection margin. All such cases had additional treatment for the microscopic residual disease. In the four cases in the PM group with involved resection margins in none was this at the area with the limited resection. The status of the resection margins in these cases would not have been different even if they had had a total maxillectomy. Morbidity in the PM group was significantly less than in the TM group. CONCLUSION: By careful case- selection based on imaging, partial maxillectomy can provide for equivalent oncologic clearance as with a Total Maxillectomy, and significantly reduced morbidity.