Post Covid-19 Acute Invasive Fungal Rhinosinusitis (AIFR): A Study of Histopathological Findings After FESS in Radiologically Diagnosed AIFR.

COVID-19 pandemic has led to a concerning surge of post-COVID-19 AIFR. Mucormycosis (BLACK fungus) is a rare but severe and life-threatening fungal infection occurred by mucormycetes, a family of moulds. More than 49,000 cases of AIFR were reported in three months in India. It primarily affects diabetics and spreads from the nasal cavity and paranasal sinuses (PNS). It also involves eye, palate, or brain. It is diagnosed clinically followed by radiological and pathological findings. We aimed to compare and analyse the pre-operative imaging with postoperative histopathological findings. The study was conducted in ENT department of tertiary care hospital, Rajkot. 200 patients were randomly selected who were presented to ENT OPD with clinically suspected Post COVID-19 AIFR. All patients underwent detailed ENT examination and radiological modality like MRI PNS, Brain, and Orbit. After proper pre-op evaluation, all patients underwent Functional Endoscopic Sinus Surgery (FESS). MRI findings were confirmed with that of histopathological findings done on KOH mount. All the patients were showing AIFR on MRI findings whereas 49% of patients had mucormycosis on Histopathology. Various other fungal infections like aspergillosis (7%), candidiasis (1.5%) were also found on HPE. 9% of patients showed combined infection with mucor and aspergillus species. Rest of the patients showed non-fungal rhinosinusitis. Inflow of the epidemic, plenty of patients were shown invasive fungal sinusitis in MRI patterns whereas many of them were HPE negative. Thus this study was done to know the efficacy of radiological features with pathological diagnosis. We have considered both procedures standard in our study.

Management of Mucormycosis in Post COVID-19 Patients and Its Outcome in a Tertiary Care Center: Our Experience.

To assess the common presentation and extent of disease involvement clinically and radiologically and treatment modalities, sequalae of the disease, complications and treatment response. Mucormycosis is a life-threatening infection that most commonly affects immunocompromised individuals and an exponential increase in the incidence of Rhino-orbital-cerebral mucormycosis was witnessed in the second wave of the COVID-19 pandemic, despite aggressive multimodal treatment carries a significant risk of mortality. A high index of suspicion is required in order to begin the appropriate diagnostic workup and treatment. This study is conducted to access the outcome and management of mucormycosis in post covid 19 patients. The prospective study includes 180 Patients, who are attending to E.N.T. outpatient department, Triage and patients referred from other departments who had suspected/confirmed Rhino-orbital-cerebral mucormycosis/underwent surgery and/or medical treatment or both. In our study mucormycosis predominantly affected age group between 40 and 60 years, more common in males (77.8%) than females (22.2%), 77.8% patients had post covid status. Most common risk factor was diabetes mellitus.76% patients had undergone endoscopic/open surgery and 24% patients underwent only medical treatment. Among 138 patients operated, 40% had recurrence and mortality was 16.1% (significantly reduced). Early diagnosis and prompt intervention is paramount to reduce morbidity and mortality. Liposomal Amphotericin B is most effective antifungal with manageable side effects. Patients who underwent Radical debridement either endoscopically or open approach, had better outcome with minimal recurrence rates. Combined medical and surgical treatment has better outcome, lesser recurrence and mortality.

Outcome of Open Surgery in Disease Progression of Post-COVID Rhinomaxillary Mucormycosis Treated by Functional Endoscopic Sinus Surgery and Proposed Evaluation Scale for Maxillary Sinus Disease and Osteomyelitis.

Introduction: Rhinomaxillary Mucormycosis (RMM) is a condition peculiarly seen as post-COVID-19 opportunistic infections with Maxillary Sinus Disease and Osteomyelitis (MSDO). The open method of debridement and closed method are two types of surgical modalities available. There is no scoring method for this infection in maxilla. This paper aims to study the clinical and CT-based outcome of open versus closed surgery of MSDO in post-COVID-19 RMM and propose a new scoring method to evaluate the disease severity, progression as well as recovery. Material and Methods: Symptomatic cases of RMM (n = 17) with a history of closed surgical treatment were enrolled for this prospective clinical study. These cases were then treated by medicinal and open surgical method. The clinical and CT scan outcomes were compared by proposed new scoring method.The CT-based score for Maxillary Sinus Disease (MSD) and Maxillary Osteomyelitis (MO) from pre-FESS (CT1), Post-FESS (Preoperative, CT2), and Post-operative (CT3) were compared for both right and left sides. One-way ANOVA test and post HOC tests were used for statistical evaluation. Conclusion: The open method of maxillary sinus surgery has given significant improvement in the treatment of RMM already treated by a closed endoscopic approach. Supplementary Information: The online version contains supplementary material available at 10.1007/s12663-022-01803-5.

Safe surgical training: evaluation of a national functional endoscopic sinus surgery model simulation course using the Kirkpatrick evaluation model.

BACKGROUND: Simulation is a rapidly developing field in modern undergraduate skills education and postgraduate surgical training. AIM: We aim to evaluate simulation training as a tool for higher surgical training in functional endoscopic sinus surgery (FESS) using the Kirkpatrick evaluation model. METHODS: This was a prospective cohort study in which a qualitative survey and multiple-choice questionnaire were distributed to otolaryngology trainees pre- and post-FESS training course using simulation models. Participants' reactions and interpretations of the models were assessed. Pre- and post-simulation knowledge and subjective skills were assessed. RESULTS: A total of 21 trainees completed the course. Trainees reported simulation models to be accurate representations of human anatomy 95% and easy to use 90%. There was an improvement in anatomical 54 to 62% (Z = 76, p0.03) and procedural 65 to 72% (Z = 87, p0.03) knowledge overall. CONCLUSION: Simulation training is an effective method of postgraduate education. This has been particularly useful following reduced operative exposure in the COVID-19 era.

Mucormycosis—The Rising Epidemic in a Pandemic: An Observational Case Study in a Tertiary Care Hospital

Mucormycosis is a rare and ominous fungal disease caused by the order Mucorales fungi. As per Indian data, uncontrolled diabetes is the main risk factor associated with mucormycosis. But during this SARS COV-2 pandemic, a huge rise in the number of mucormycosis cases has been observed in different states in India in last 10-12 months in the second wave. The immune dysfunction caused by this virus and the use of high doses of steroids appears to be a double-edged sword and causes immunosuppression with hyperglycemia, increasing the risk of secondary bacterial and invasive fungal infections (IFIs). Objective We conducted a prospective observational study involving individuals with proven mucormycosis in ABVIMS & Dr RML Hospital, New Delhi. The demographic profile with various clinical presentations, histopathological findings, predisposing factors, management, and final outcomes were recorded. Results We included 53 patients in our study. Rhino-orbital-cerebral mucormycosis was the most common (21/53, 39.6%) presentation followed by rhino-orbital (17/53, 32.0%), rhino-cerebral (10/53, 18.8% ) rhinosinusitis (4/53, 7.5%) and pulmonary involvement in 1/53, (1.8%). The cutaneous involvement was seen in 8 patients (15.0%), disseminated mucormycosis as meningitis in 2 patients (3.7%), and dual fungal infection with aspergillosis was seen in 2 patients (3.7%). The predisposing factors being diabetes mellitus (40/53, 75.4%), with newly diagnosed diabetes in previously undiagnosed (10/ 53, 18.8%), SARS-COV-2 (33/53, 62.2%), steroid intake (30/53, 56.6% ), prolonged hospital stay (29/53, 54.7%), use of oxygen therapy (19/53, 35.8%), and diabetic ketoacidosis in 2 patients (3.7%) Amphotericin B (liposomal form) was the primary therapy in all 53 patients. Hypokalemia (8/53, 15.0%) was seen as side effect of amphotericin-B although renal functions were normal in all patients. Surgical debridement was performed in 43(77.3%) patients and transcutaneous retrobulbar amphotericin-B (TRAMB) was given in 16 patients (30.1%). Total mortality in our study is of 9 patients (16.9%). Conclusions Diabetes mellitus was the dominant predisposing factor in all forms of mucormycosis which also includes newly diagnosed diabetes. Hyperglycemia and immune dysregulation by SARS-CoV-2 and high dose corticosteroid use on large scale served a favorable environment for this invasive fungus.

IMMEDIATE RESTORATION OF OLFACTORY FUNCTION FOLLOWING COVID-19 INFECTION IN A PATIENT WITH ANOSMIA DUE TO FUNCTIONAL ENDOSCOPIC SINUS SURGERY COMPLICATION – A CASE REPORT

The authors present a case of a 50-year-old female patient with a history of chronic rhinosinusitis, for which she underwent functional endoscopic sinus surgery. This significantly improved respiration, but left her with a self-reported complete loss of olfactory function. Six years later, still with unresolved anosmia, she tested positive for COVID-19 a few days after she had been vaccinated with the first dose of Pfizer BioNtech COVID-19 vaccine (Pfizer, New York, NY, US). The disease course was uneventful, and she remained asymptomatic. One day after the diagnosis of COVID-19 infection, she reported a sudden complete return of her olfactory function, which has remained stable until now, 3 months after her recovery from COVID-19 infection. The physiologic dynamics under-lying this event are a mystery. © 2021, EDRA S.p.A. All rights reserved.

Rhinocerebral Mucormycosis With Brain Abscess Presenting as Status Epileptucus in a COVID-19-Infected Male: A Calamitous Complication.

With the evolution of COVID-19 disease, the emergence of more complications associated with COVID-19 is taking place. Mucormycosis is the most common opportunistic fungal infection encountered after COVID-19. In this case report, we describe a case of a 61-year-old male type 2 diabetic with sino-orbital-cerebral mucormycosis infection who was treated with conventional guidelines for a recent COVID-19 infection and further presented with generalized tonic-clonic status seizures. Neuroimaging revealed sino-orbital mucormycosis with right frontal lobe abscess. He was treated with anti-epileptics, steroids, amphotericin-B, and functional endoscopic sinus surgery (FESS).

Remote Training of Functional Endoscopic Sinus Surgery With Advanced Manufactured 3D Sinus Models and a Telemedicine System.

Objective: Traditionally, cadaveric courses have been an important tool in surgical education for Functional Endoscopic Sinus Surgery (FESS). The recent COVID-19 pandemic, however, has had a significant global impact on such courses due to its travel restrictions, social distancing regulations, and infection risk. Here, we report the world-first remote (Functional Endoscopic Sinus Surgery) FESS training course between Japan and Australia, utilizing novel 3D-printed sinus models. We examined the feasibility and educational effect of the course conducted entirely remotely with encrypted telemedicine software. Methods: Three otolaryngologists in Hokkaido, Japan, were trained to perform frontal sinus dissections on novel 3D sinus models of increasing difficulty, by two rhinologists located in Adelaide, South Australia. The advanced manufactured sinus models were 3D printed from the Computed tomography (CT) scans of patients with chronic rhinosinusitis. Using Zoom and the Quintree telemedicine platform, the surgeons in Adelaide first lectured the Japanese surgeons on the Building Block Concept for a three Dimensional understanding of the frontal recess. They in real time directly supervised the surgeons as they planned and then performed the frontal sinus dissections. The Japanese surgeons were asked to complete a questionnaire pertaining to their experience and the time taken to perform the frontal dissection was recorded. The course was streamed to over 200 otolaryngologists worldwide. Results: All dissectors completed five frontal sinusotomies. The time to identify the frontal sinus drainage pathway (FSDP) significantly reduced from 1,292 ± 672 to 321 ± 267 s (p = 0.02), despite an increase in the difficulty of the frontal recess anatomy. Image analysis revealed the volume of FSDP was improved (2.36 ± 0.00 to 9.70 ± 1.49 ml, p = 0.014). Questionnaires showed the course's general benefit was 95.47 ± 5.13 in dissectors and 89.24 ± 15.75 in audiences. Conclusion: The combination of telemedicine software, web-conferencing technology, standardized 3D sinus models, and expert supervision, provides excellent training outcomes for surgeons in circumstances when classical surgical workshops cannot be realized.

The microscope drape method to reduce aerosolisation during endoscopic sinus and skull base surgery in the COVID era. How i do it.

BACKGROUND: Otolaryngologists are faced with concerning challenges since the onset of the coronavirus disease (COVID-19) pandemic due to significant risk of occupational infection. Transmission can happen during intraoperative exposure to viral particles carried by droplets or aerosols. Endoscopic sinus and skull base surgery are notable for causing aerosolisation, putting healthcare staff at substantial risk. METHOD: We describe the creation of a tight-seal tent from a microscope drape covering the operative field and the operator's hands with the aim to contain aerosols during transnasal endoscopic surgery. CONCLUSION: The microscope drape technique is a simple barrier measure that could potentially improve safety during endoscopic procedures.