Strangulated obturator hernia in a COVID-19 patient: a rare case presentation and the role of computed tomography in diagnosis

Obturator hernia is a rare cause of acute abdomen resulting from a protrusion of intra-abdominal contents through the obturator foramen in the pelvis. Obturator hernia is often seen in older adults, emaciated individuals, and chronically ill women. The preoperative diagnosis of obturator hernia is frequently delayed because its nonspecific signs and symptoms complicate the diagnostic pro-cess, leading to high mortality rates. The most common clinical presentation of obturator hernia is intestinal obstruction with nausea, vomiting, and abdominal pain. Symptoms caused by the compression and irritation of the obturator nerve within the canal are less common. Open or laparoscopic surgery is the only available treatment;it allows abdominal cavity exploration and hernia reduction. The widespread and increasing use of computed tomography has played an important role in diagnosing conditions. Here, we present the case of a 90-year-old woman di-agnosed with strangulated obturator hernia and coronavirus disease 2019 (COVID-19) who under-went emergency surgery at Hanoi Medical University Hospital. We emphasize the role of computed tomography in establishing a prompt preoperative diagnosis and planning an appropriate surgical intervention for this rare condition.

Prosthetic rehabilitation of post-COVID mucormycosis

Mucormycosis is one of the most rapidly fulminating fatal mycotic infections in human beings leading to necrosis and destruction of the involved structures. Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2, has been associated with a wide range of opportunistic bacterial and fungal infections. Increasing case of mucormycosis has been seen in patients affected by COVID-19. This article includes a case report on diagnosis, pharmacological, surgical management, and prosthetic rehabilitation of post-COVID mucormycosis.

Magnet-Retained closed bulb hollow obturator and orbital prosthesis for patient with maxillectomy and orbital exenteration following COVID-Associated mucormycosis.

The rehabilitation of facial deformities is a challenging endeavour that necessitates customising the procedure for each patient. Significant physical and psychological impacts might arise as a result of the deformity in the orofacial region. Post-COVID rhino-orbital mucormycosis has led to rise in extraoral and intraoral defects since 2020. To avoid further surgery, an economical maxillofacial prosthesis is an excellent choice as it is aesthetic, durable, long-lasting and retentive. This case report describes the prosthetic rehabilitation of the patient with post-COVID mucormycosis maxillectomy and orbital exenteration using a magnet-retained closed bulb hollow acrylic obturator and room-temperature vulcanising silicone orbital prosthesis. To enhance retention, a spectacle and medical-grade adhesive were also used.

Prosthetic Rehabilitation of A Post-Covid Mucormycosis Maxillectomy Defect Using A Fused Two-Piece Hollow Obturator: A Fabrication Technique

Purpose: Intraoral defects in the maxilla cause communication with the nasopharyngeal complex. The surgically removed palate can have a devastating effect on the appearance and speech of the patient. Obturators allow patients to eat and drink without any suspicion of food entering the oroantral cavities/ pharynx during mastication. This clinical report describes fabrication of a closed hollow bulb obturator using the two-piece double flask technique. Method(s): After the final teeth arrangement was completed, teeth over the defect were removed and separately processed using heat cure acrylic resin. Both the segments are combined by autopolymerizing acrylic resin to form a single hollow-bodied obturator. Conclusion(s): This technique uses a double flasking method of the two segments to control the thickness of the bulb in the defect area, thus decreasing the weight of the obturator.Copyright © 2020 Ubiquity Press. All rights reserved.

Hollowing of Delayed Surgical Obturator in Maxillectomy Defects Secondary to Mucormycosis in Post-COVID-19 Era: A Case Series

During the second wave of the coronavirus disease 2019 (COVID-19) pandemic in India, there was an increase in the surge of mucormycosis cases secondary to COVID-19 infection. Aggressive surgical debridement is the most common treatment modality opted for its treatment that leads to extended maxillary defects. Obturating such defects may be very challenging from a prosthodontic point of view, as larger defect sizes and fewer retentive areas make it difficult to retain the prosthesis. A delayed surgical obturator is a prosthesis that is placed 6–10 days after the surgery, mainly used to minimize postoperative complications. It reproduces the contour of the palate and allows the patient to resume a regular diet. It also assists in normal speech. But in large surgical defects, the increased obturator's weight makes it uncomfortable and nonretentive for the patient, compromising its function. Consequently, in this case series, hollow bulb obturators are fabricated to decrease the weight of the prosthesis and to improve the function by establishing palatal contour. In case 1, hollowing was done using thermoplastic polyvinyl chloride (PVC) sheets and in case 2 acrylic shim was used. In both cases two-layer techniques were used, as in large defects if we use a single-layer technique it will either increase the weight of the prosthesis or may fail to create a palatal contour that further compromises the function. The techniques followed here are easy to use and less time-consuming. © The Author(s). 2022.

Futuristic Rehabilitation Technique Of Acquired Maxillectomy Defect In Post Covid19 Mucormycosis Using Polyether Ether Ketone Obturator Prosthesis- A Case Report

Background: Oroantral communication can occur due to maxillectomy defects, jeopardizing the integrity and function of oral cavity. It is an interdisciplinary challenge to restore these by surgery and prosthetics since many facets need to be addressed, such as speech, deglutition, mastication, aesthetics and psychological distress. Rationale: Surgical repair of maxillectomy defects is not always achievable due to various reasons such as poor systemic health, advanced age etc. Thus prosthetic rehabilitation becomes the most suitable treatment option. Relevance for Patients: Post COVID-19 mucormycosis has seen a surge in the past two years. It is an opportunistic fungal infection in humans infecting intracranial structures by direct invasion in the blood stream. Fundamental goal of prosthetic rehabilitation is the closure of oronasal communication and restoring it functionally thereby improving quality of life for the patient. CAD/CAM (computer aided design/computer aided milling) technology was employed to fabricate a milled framework for maxillary obturator in the most innovative way using PEEK (Polyether ether ketone). Result(s): PEEK material due to its excellent biocompatibility ensured a light weight prosthesis for the large maxillectomy defect and closure of the patency was achieved by the obturator framework.Copyright © 2022 Authors. All rights reserved.

Post maxillectomy rehabilitation and amelioration of quality of life of post-COVID rhinocerebral mucormycosis patients using obturator: A case series.

Mucormycosis, a rare fungal infection seen in diabetes, is now very frequent owing to the deadly triad of COVID-19 infection, diabetes, and rampant use of corticosteroids. Early diagnosis and treatment can reduce the mortality and morbidity of this lethal fungal infection. Treatment principles may include antifungal agents along with surgical debridement or resection. The surgically removed palate can have a devastating effect on the appearance and speech of the patient. Obturators allow patients to eat and drink without any suspicion of food entering the oroantral cavities/pharynx during mastication. This case series presented the prosthodontic rehabilitation of nine post-COVID rhinocerebral mucormycosis-infected patients with complete or partial defects.

Post maxillectomy definitive rehabilitation in post-covid mucormycosis patients using conventional and 3D printed obturator: A twin case report

Maxillectomy is the surgical removal or resection of the maxilla or upper jaw bone. Maxillectomy may be total or partial. It is performed during surgical treatment of cancer and infections (bacterial. fungal) of the oral cavity, nasal cavity and maxillary sinuses. Patient affected from post-Covid mucormycosis require local debridement or surgical resection resulting in maxillectomy. After surgery, patient has difficulty in mastication, speech, and swallowing because of communication between oral and nasal cavity. This may also give rise to psychological challenges and social exclusion. The prosthodontic rehabilitation of such patient using obturator provide a separation between oral and nasal cavity and improve the quality of life of the patient. There are various techniques and materials used for fabrication of definitive obturator. This article discusses the prosthodontic rehabilitation after maxillectomy in post-covid mucormycosis patients using obturator by conventional and 3D printed techniques. © 2022 Manu Rathee et al., published by Sciendo.

Application of Polyvinyl chloride sheet as delayed surgical obturator in maxillectomy defects secondary to mucormycosis- A case series.

It was a great challenge for the prosthodontist to rehabilitate and sustain the prosthesis in patients with bilateral maxillectomy defects due to mucormycosis seen with Covid-19 during second wave in India. In such extensive defects there was difficulty in retaining the obturator due to the absence of soft tissue or anatomical undercuts, condition of existing dentition, retained inferior turbinates and limitation in taking retention from defect side during healing phase. In such extensive maxillectomy defects, retention, stability and support can be enhanced by maximum preservation of hard and soft tissues, skin grafting and removal of inferior turbinates to provide a larger surface area for stress distribution. But here, in this case series, maxillectomy defects with retained inferior turbinates presented a problem in retaining the obturator prosthesis due to limitation in taking retention from the defect side. The conventional method of fabrication of obturator using autopolymerizing acrylic failed in terms of weight of the prosthesis and in gaining retention from the defect side during healing phase. Therefore, thermoplastic vacuum pressed Polyvinyl chloride sheet (PVC) was used for fabrication of delayed surgical obturator due to many merits conferred by it. Its light weight, non porous nature, easy adaptability, patient comfort, efficient undercut engagement, hygienic nature makes it a good treatment option. The main cocern was to close oro-nasal communication to eliminate the need of nasogastric tube and to prevent nasal regurgitation. In all cases, patients were comfortable with the obturator prosthesis in terms of adaptation and function.

Dental Perspective on Mucormycosis in COVID-19: a Literature Review.

Purpose of Review: The purpose of this paper is to gain an understanding of existing knowledge and attain familiarity on mucormycosis for early diagnosis and treatment. It highlights the systematic factors, signs and symptoms, diagnostic tests and treatment procedure for mucormycosis from dentistry point of view. PubMed/ Medline, Scopus, Web of Science were the search engine used. Study selection encompassed systematic reviews, critical reviews and case reports related to mucormycosis in COVID-19 patients and only mucormycosis. 19 articles were selected between Years 2001 to 2021. Analysis was done based on patient's comorbidity, site of mucormycosis infection, use of steroids and its effect on people with COVID -19 infection. Recent Findings: Rhino-orbito-cerebral mucormycosis is the most common of all systemic manifestations of mucormycosis. Diabetes mellitus and long-term corticosteroid therapy are the leading risk factors with pre-existing diabetes mellitus accounting for almost 80% cases.  Elements that facilitate the growth of mucor in COVID-19 patients are the presence of low oxygen levels, high blood glucose levels, acidic media, high levels of iron, immunosuppression, and episodes of prolonged hospitalization. Mucormycosis is heterogenic in nature. Its management requires an individualized plan that considers the immunity status of the host, stage of the infection, systemic disease, early diagnosis and susceptibility to anti-fungal agents. Supervised use of corticosteroids and betadine gargle prevent the occurance of mucormycosis. Summary: The paper sheds some light on the warning signs and diagnostic tests that can help in early identification of infection by a dentist. This enables the timely implementation of therapy resulting in good prognosis of the treatment.

Intraoral customized Z-spring-retained delayed surgical obturator for rare cases of bilateral subtotal maxillectomy.

While dealing with a grave second wave of ongoing pandemic COVID-19, India also saw a surge in cases of COVID-19-associated mucormycosis, a systematic fungal infection caused by the Mucorales species. Mucormycosis is a highly angioinvasive, rapidly spreading fungal infection. In numerous cases of mucormycosis, bilateral subtotal maxillectomy was performed due to unpredictable and indefinable advancement of fungus clinically. Effective obturation of bilateral maxillectomy defect is a difficult task and as this is a relatively uncommon surgical problem, insufficient data are available on the construction of delayed surgical obturator for such cases. The aim of this article is to discuss the design of Z-spring-retained delayed surgical obturator which is easy to fabricate, easy to rectify, cost-effective, and comfortable for the patients compared to previous spring-retained obturators. This surgical obturator is retained through Z-spring made of 1.02 mm thick wire. Due to the thick gauge, this spring counters postsurgery trismus and develops the seal between the acrylic plate and dorsum of the tongue during deglutition thus helps the patient in taking a soft diet initially. Novelty in this case is the design of the spring, which makes it beneficial for both patient and prosthodontist.

Fabrication of single piece definitive obturator for post surgical maxillectomy defect during covid-19 pandemic-A Literature review with Clinical case report

Background: Impacts of primary oncology surgical procedure can impede restoration objectives. Restoring oral function, comfort and aesthetics is a challenge due to limitations in the restorative treatment options. Methodology: Literature review on the responsibilities, role of maxillofacial prosthodontist, materails and retentive aids used for prosthesis, classification of maxillofacial prostheses, recent advancements in MFP and Workflow for the fabrication of obturator prostheses in the COVID-19 pandemic scenario. Case report on the fabrication of Holllow bulb definitive obturator during pandemic crisis. A 47 years old male patient reported for post-surgical evaluation in maxillary posterior region of oral cavity. The patient had partial maxillectomysurgical procedure of squamous cell carcinoma in the palate 5 years back. To replace the gap created, the patient was using interim obturator. He had facial asymmetry and collapse. Prosthodontic rehabilitation with one piece closed hollow bulb obturator was planned & subsequently fabricated for the patient. For our case considering the feasibility & ease of manipulation, heat activated acrylic resin was used for this particular patient for rehabilitation. The method described is easy, simple, time saving & economical. Bulb portion was hollow & made of heat cure resin, so weight was less & less chances of tissue irritation. Results: With the Covid-19 infection protocol measures taken definitive obturator was given to the maxillectomy patient to restore aesthetics, function and comfort as well. After insertion of prostheses mastication, deglutition and phonetics were improved. Breathing problems were resolved and aesthetics was improved. Conclusion: A simplified technical approach for the treatment of a patient with palatal defect of and other supportive structure has been presented in Covid-19 situation following the described infection prevention protocols. The technique presented offers a method of obtaining a detailed impression of the defect and promptly provides the patient with a light weight, easyto-use and flexible tissue-tolerant obturator.

CASE REPORT of A HARD to TREAT DERMATOMYOSITIS after A COVID-19 INFECTION and SUBSEQUENT VACCINATION

Background: A 50 years old woman, a medical doctor, came to our department with symmetrical proximal muscular weakness, several months after Covid-19 infection and three weeks after a second dose of Covid-19 mRNA vaccine. The patient had no prior or family history of autoimmune diseases and take no medicines. In the past she undergone an operation for double-kidney with frequent urinary infections. Objective fndings have shown symmetrical proximal muscular weakness and classic sings of dermatomyositis-Gottron's papules, shawl and holster signs, periungual vasculitis. Objectives: We present a case of a 50 old woman with clinical and laboratory proven dermatomyositis, starting three weeks after a second dose of a Covid1-19 mRNA vaccine without other reasons. Methods: The laboratory tests showed elevated CPK, lactate dehydroge-nase, aspartate aminotransferase and alanine aminotransferase, high ANA-1:1280 and myositis specifc autoantibodies-anti-NXP2 and anti-Mi-2-beta. The electromyography showed myopathic changes and the muscle MRI-symmetrical edema of mm.obturator and mm.adductor brevis. We exclude diseases that may mimic infammatory myopathies. We made a cancer screening-whole body MRI, colonoscopy, gastroscopy, mammography and gynecological exam, immunoblot for detection of paraneoplastic syndrome-associated neuronal antibodies, with no detection of cancer. Muscle biopsy of m.vastus lateralis showed attenuating muscle infammation with advancing muscle atrophy and fbrosis. Results: The diagnose dermatomyositis was made according Bohan and Peter criteria and we start a high dose (1mg/kg/day) glucocorticoid therapy with good initial clinical and laboratory effect. Two months after starting a therapy muscle weakness worsened together with difficulty of swallowing. We excluded steroid myopathy after second EMG and lack of improvement when tapering the GS dose. Methotrexate 20 mg/weekly was added as a steroid sparing drug with good response, but was stopped because fare of pyelonephritis. Accordning to the opinion of dermatologist hydroxychloroquine was started for a couple of weeks, because of active skin manifestations. Muscle weakness worsened on the background of treatment, which was stopped. We started a therapy with intravenous immunoglobulins and considered therapy with cyclophosphamide or azathio-prine after urinary infection. Because the patient was infected for a second time with covid-19, although vaccine, we continued only with glucocorticoids and anti-osteoporotic therapy. Conclusion: The etiology and pathogenesis of infammatory myopathies are not fully clarifed so far. We speculate that the infection with Covid-19 as well as mRNA vaccine trigger infammatory myopathy and compromise the patient's immunity for poor treatment response with glucocorticoids and immunosuppres-sives. On the other hand advanced muscle atrophy and fbrosis within a short period show that suspected triggering factors could be a reason for difficult to treat such type of dermatomyiositis.

MINI OR RETROPUBIC SLING IN WOMEN WITH INTRINSIC SPHINCTER DEFICIENCYAT 6 MONTHS- AN RCT (MINI RISD)

Introduction: Intrinsic sphincter deficiency (ISD) is associated with a higher risk of sling failure and is difficult to treat. The retropubic (RP) sling and the “mini” single incision sling (SIS) are two treatment options. Comparison of the efficacy and safety for these procedures in an ISD population has not been determined. The RP sling has been shown to be superior to the obturator sling for the treatment of SUI associated with ISD1, however the RP sling is associated with more complications such as bleeding, bladder injury and voiding difficulty2,3. SISs provide a “hammock” support and are able to be placed under more tension than an obturator sling. It is plausible that SISs could be as effective as the retropubic sling but associated with less complications. Objective: To assess if the SIS is as efficacious as the RP sling for women with urodynamic stress incontinence (USI) and ISD and compare clinical outcomes. Methods: This was a multicenter randomized controlled trial involving women with SUI/ISD. Demographic data of eligible women and POPQ examination was collected. Randomization to SIS or RP occurred in equal probability. Concomitant prolapse operation was performed as required. Post-operative interview and examination were performed at 6 weeks and 6 months. Examination included uroflow, cough stress test and POPQ assessment. Standardized questionnaires were performed at 6 months. Primary outcome was to assess the objective cure rate (negative clinical cough stress test) of the SIS against the RP sling at 6 months post- surgery. Secondary outcomes included immediate and short term post-operative complications and patient reported outcomes. Categorical Outcomes were compared using the chi-squared test and continuous outcomes using the independent samples t-test for normally distributed data. Results: 112 women have been randomized and completed 6 month follow up. 54 women were randomized to SIS and 58 women to RP sling. Results were analyzed by at ITT analysis. No women crossed groups. We did not achieve our sample size of 132 due to a combination of factors including withdrawal of approval of the SIS from the local regulatory body, Covid restrictions on recruitment/surgery and women's reluctance to have mesh. Average age was 66 years and BMI 27. Table 1 shows results at 6 months. There was no difference in post-operative complications between the 2 groups however, one SIS was removed for groin pain. At 6 months, women who had no symptoms of SUI (72% RP group versus 72% SIS) and who had a negative cough stress test (87% RP versus 82% SIS) were similar. 78% in the RP group and 76% in the SIS group reported improvement as “very much better or much better” (RR 1.06 (95% CI 0.68-1.66), P = 0.79). 2 women had repeat surgery at 6 months. One in the RP group (1.7%) and one in the SIS group (1.9%). At 2 years, 4 women in the RP group (6.9%) had repeat surgery and 6 in the SIS group (11.1%). Conclusions: After six months, we are unable to show a difference in subjective or objective cure between groups. With time, more women had repeat surgery (Table Presented).

Little Old Lady's Hernia with Hiatus Hernia- A Case Report

With the outbreak of the Coronavirus Disease-2019 (COVID-19) pandemic, it is not uncommon to see patients who present with respiratory symptoms secondary to an abdominal pathology, being suspected of having COVID-19. Here, authors report a case of an elderly female who presented with recent-onset dyspnoea, shortness of breath, pain abdomen and non passage of flatus and stools. Examination revealed that the patient had tachycardia, tachypnoea, and dyspnoea with an oxygen saturation (SpO(2)) of 92%. Her abdomen was distended, non tender with no free fluid detected. All the hernial orifices were free. Computed Tomography (CT) scan revealed a left diaphragmatic hernia and a left-sided obturator hernia with obstructed ileal segment. However, intraoperatively a Type IV hiatus hernia was discovered, where the Gastrooesophageal (GE) junction, stomach, colon, and omentum were the contents. This case highlights an unusual clinical presentation of a rare cause of intestinal obstruction and its management during the COVID-19 pandemic. Obstructed obturator hernia is associated with high morbidity and mortality.

Assessment of Impact of Prosthodontic Intervention on the Oral Health Related Quality of Life among Post COVID-19 Mucormycosis Affected Individuals in Central India

Introduction: The currently prevalent Coronavirus Disease 2019 (COVID-19) pandemic has amounted to various co-morbid conditions amongst patients and mucormycosis has been one among them. A globally emerging disease, this requires aggressive surgical treatment that necessitates due prosthetic rehabilitation. Aim: To assess the impact of prosthodontic intervention on the Oral Health Related Quality of Life (OHRQoL) through Oral Health Impact Profile 14 (OHIP-14) questionnaire in post COVID-19 mucormycosis affected individuals. Materials and Methods: The following study was a questionnaire-based prospective interventional study. The study population included post COVID-19 mucormycosis affected individuals who sought prosthodontic therapy for rehabilitation from the month of April 2021 to October 2021. The study instituted the questionnaire amongst 48 consenting participants. The OHIP-14 questionnaire was validated in their native languages and data was collected before and one month after prosthodontic intervention. Data was statistically analysed by the Wilcoxon signed-rank test. Results: For all the individual questions, OHRQoL impact showed a significant decrease following prosthetic intervention (p-value <0.05). Total OHIP score also showed a significant decrease post-treatment (p-value=0.001). Conclusion: Percentage improvement of OHRQoL ranging from 34.79% to 59.86% post prosthodontic intervention was observed. Thus, the impact of prosthodontic therapy among post COVID-19 mucormycosis affected individuals on the OHRQoL of the patient is positively significant.

Post surgical immediate prosthetic reconstruction in patients with rhinocerebral mucormycosis: Case series.

Coronavirus disease has taken a toll on everyone's lives either physically or emotionally throughout the world. One of the most serious complications occurring currently in covid-positive and recovered patients is the deadly invasive mucormycosis. There are five clinical types of mucormycosis, out of which rhino-orbito-cerebral is the most common form (44%-49%). Management includes early diagnosis, control of the underlying diseases, and aggressive medical and surgical intervention. In patients undergoing maxillectomies, the use of immediate surgical obturators has become the gold standard. The rationale for its use is threefold-functional (matrix for the surgical dressing; allows the patient to speak and swallow), hygienic (separates the maxillary surgical site from contents of the oral cavity), and psychological (restores patient's self-image by reproducing lost oral structure). This article includes two case reports of patients diagnosed with rhinocerebral mucormycosis. The surgical debridement, medical management, and immediate reconstruction using palatal obturators have been explained.

Strategic use of obturator prostheses for the rehabilitation of oral cancer patients during the COVID-19 pandemic.

During the current pandemic scenario, maxillofacial rehabilitation specialists involved with supportive care in cancer must transform its practice to cope with COVID-19 and improve protocols that could quickly return the oral function of complex cancer patients who cannot wait for surgical complex rehabilitation. This includes the role of the maxillofacial prosthodontist for the rehabilitation of surgically treated patients with maxillary cancers by the means of filling obturator prostheses that are considered an optimal scientific-based strategy to reduce hospital stay with excellent pain control, oral function (speech, swallowing, mastication, and facial esthetics), psychologic and quality of life outcomes for the patients following intraoral cancer resection. Therefore, the aim of this commentary was to bring new lights to the strategic use of obturator prostheses for the rehabilitation of oral cancer patients during the COVID-19 pandemic as well as to present a protocol for managing such cases.