Sleep Testing as a Pre-requisite for Commercial Motor Driving License is a Need of the Hour.

Commercial drivers, including pilots, suffering from untreated sleep-related disorders endanger many lives. This puts them at risk of increased daytime somnolence. Through this brief communication, we urge the authorities to make the sleep study mandatory for these drivers to diagnose underlying sleep disorders like sleep apnea.

Utility of in-house and commercial PCR assay in diagnosis of Covid-19 associated mucormycoss in an emergency setting in a tertiary care center.

Introduction. Invasive mucormycosis (IM) is a potentially fatal infection caused by fungi of the order Mucorales. Histopathology, culture, and radiology are the mainstays of diagnosis, but they are not sufficiently sensitive, resulting in delayed diagnosis and intervention. Recent studies have shown that PCR-based techniques can be a promising way to diagnose IM.Hypothesis/Gap Statement. Early diagnosis of fungal infections using molecular diagnostic techniques can improve patient outcomes, especially in invasive mucormycosis.Aim. The aim of this study was to evaluate the utility of our in-house mould-specific real time PCR assay (qPCR) in comparison with the commercially available real time PCR (MucorGenius PCR), for the early diagnosis of mucormycosis in tissue samples from patients with suspicion of invasive mucormycosis (IM). This in-house assay can detect and distinguish three clinically relevant mould species, e.g. Aspergillus spp., Mucorales and Fusarium spp. in a single reaction with only one pair of primers, without the need for sequencing.Methodology. We enrolled 313 tissue samples from 193 patients with suspected IM in this prospective study. All cases were classified using EORTC/MSGERC guidelines. All samples were tested using traditional methods, in-house qPCR, and MucorGenius PCR.Results. Using direct microscopy as a gold standard, the overall sensitivity and specificity of in-house qPCR for detection of IM was 92.46% and 80% respectively, while that of the MucorGenius PCR was 66.67% and 90% respectively. However, co-infection of IM and IA adversely affected the performance of MucorGenius PCR in detection of IM.The in-house PCR detected Aspergillus spp. in 14 cases and Fusarium spp. in 4 cases which showed clinical and radiological features of fungal sinusitis. The in-house qPCR also performed better in detecting possible cases of IM. This aids early diagnosis and appropriate treatment to improve patient outcomes.Conclusion. Because the in-house PCR is not only sensitive and specific, but also entirely based on SYBR Green for detection of targets, it is less expensive than probe-based assays and can be used on a regular basis for the diagnosis of IM in resource-constrained settings. It can be used to distinguish between mucormycosis and fungal sinusitis caused by Aspergillus and Fusarium in high-risk patients, as well as to accurately detect Mucorales in fungal co-infection cases.

Factors affecting clinical outcome in COVID-associated rhino-orbito-cerebral mucormycosis (CAROM) patients-An ambispective, single-arm, observational study.

BACKGROUND: COVID-associated Rhino-Orbito-Cerebral Mucormycosis (CAROM) appeared as an epidemic in India during the second wave of the COVID-19 pandemic during the months of March to May 2021. Though many reports have highlighted cross sectional and short-term attributes related to CAROM, long term follow up data is sparse. OBJECTIVE: This report aims to analyze the follow-up outcomes in consecutive patients presenting to us during the epidemic. PATIENTS AND METHODS: This was an ambispective observational analytical study, recruiting the consecutive patients admitted to our tertiary care centre during the period of the CAROM epidemic. The mortality rate during the follow-up and various factors affecting survival were studied using univariable and multivariable statistics with the Stata 14.0 software. RESULTS: Of the 189 patients studied, eight were lost to follow-up. The outcome analysis was performed for the 181 patients. 93.6 % (162/173) of the patients had diabetes. The All-cause mortality was 45 % (81/181), while the ROCM-specific mortality was found to be 24 % (46/181) at a median follow-up of 176 days (IQR: 21-217 days). With univariable analysis, increasing age, higher serum IL-6 levels, presence of additional comorbidities (in addition to Diabetes and hypertension), bilateral disease, skin necrosis, palatal involvement, infratemporal fossa involvement, and impaired vision/ocular movements were found to be associated with increased mortality. However, on multivariable analysis, only 1) increasing age, 2) raised serum IL-6 levels, and 3) bilateral disease were predictive of increased mortality. Surgical debridement (endoscopic, palatal removal, orbital exenteration, neurosurgical intervention) was associated with significantly reduced mortality on both univariable and multivariable analysis. CONCLUSION: Our intermediate-term follow-up data showed advanced age at presentation, raised IL-6 levels, and bilateral sinonasal involvement to be predictive of increased mortality, while surgical debridement is significantly protective from mortality in CAROM patients.

A Study of Round Window and its Adjacent Anatomy to Guide the Cochlear Implant Electrode Insertion.

Introduction: Residual hearing preservation has gained attention now which has brought round window membrane into the light, as a port for cochlear implantation. Atraumatic insertion of electrodes can be achieved by study of anatomical variations of round window and its forms which can guide the surgeon. Objective: This study was undertaken to examine the anatomical variations of round window and its adjacent structures and their impact on surgical approach during cochlear implantation. Methods: A series of 40 adult human temporal bones underwent high-resolution CT scanning and were further dissected for microscopic study of the round window. Results: The antero posterior dimensions of RW ranged from 1.22 to 2.51 mm on radiology and on dissection 1.76 mm +/- 0.3 mm. Shape of round window in 72.5% of bones was oval, and in 27.5% bones it was round shaped. As per Saint Thomas hospital classification for Round window visualization we found 82.5% bones had type I RW visualization and 17.5% had type IIa RW visualization. Area of crista fenestra on dissection was ranging from 0.41 to 0.69 mm2. Conclusion: Residual hearing preservation has become a new motto for surgeons. Therefore thorough anatomic knowledge of round window is must for careful insertion, as round window is closely related to the sensitive inner ear structures.

The Role of Serum Galactomannan Assay as a Potential Surrogate Biomarker for Fungal Microinvasion in Allergic Fungal Rhinosinusitis.

We conducted this study to determine if serum galactomannan (GM) can be used as a marker to implicate the invasiveness of allergic fungal rhinosinusitis (AFRS), and correlate this value with the aggressiveness of disease documented via computed tomography (CT). All paranasal CT scans done for AFRS patients prospectively over a five-year period (2015-2019) were included. An indigenous 20-point score was used to document the extent of bone erosion seen on CT, wherein a higher score meant a greater extent of bone erosion. It was then correlated with serum GM scores. The median CT scores of galactomannan-positive (GM+) patients were compared with the median CT scores of galactomannan-negative (GM-) patients 3 using Mann-Whitney U test. The patients were divided into five groups based on the extent of disease-No bone erosion, erosion of only sinus wall/orbit, 3 erosion of orbit and skull base, erosion of only skull base and lateral extension of disease into infratemporal fossa (ITF). Subgroup analysis was conducted over mean GM values in these groups using ANOVA test. p-value < 0.05 was considered significant. Statistical analysis was performed using SPSS version 25.0. A total of 92 patients were included (56 males, 36 females). No statistically significant difference was found (p-value = 0.42) between the CT scores of galactomannan-positive (GM+) group and galactomannan-negative (GM-) group. The mean GM scores amongst the five sub-groups did not show a statistically significant difference. Serum galactomannan values correlate poorly with aggressiveness of disease quantified on non-contrast CT of paranasal sinuses.

Immunohistochemical Analysis of the Expression of Cytokeratins in Acquired Cholesteatoma and Its Clinico-Radiological Correlation.

BACKGROUND AND OBJECTIVES: Cholesteatomatous chronic otitis media acquires epithelial proliferation and differentiation characteristics, which render it able to erode the underlying bone and cause complications. We attempt to characterize the cholesteatoma epithelium by observing the expression of cytokeratins (such as 34ße12, CK17, and CK13) and Ki67 among patients with cholesteatoma with different aggressiveness as compared to disease-free controls. Subjects and. METHODS: In this prospective study (2017-2021), we enrolled all consenting consecutive patients with cholesteatomatous chronic otitis media. They were staged in accordance with the staging guidelines of the European Academy of Otology and Neurotology and the Japanese Otological Society. Bony external auditory canal (EAC) skin specimens of the patients undergoing tympanoplasty were chosen as controls. We did an immunohistochemical analysis of the cholesteatoma specimens and normal bony EAC controls by observing the expression of 34ße12, CK17, CK13, and Ki67 across the layers of the epithelium. Fisher's exact test and chi-square test were used to evaluate any statistical significance between the cases and the controls, and the subgroups were made based on the clinical stage. RESULTS: An increased expression of CK17 (p<0.001), CK13 (p<0.03), and Ki67 (p<0.001) was observed in cholesteatoma specimens when compared to normal bony EAC controls. Also, there was a loss of expression of 34ße12 in a subset of cholesteatoma specimens, all of which showed full-thickness expression of CK13. There was no difference in the expression of cytokeratin among specimens from patients belonging to different subgroups based on clinical stage, age, sex, duration of ear symptoms, or type of hearing loss (conductive vs. sensorineural). CONCLUSIONS: The majority of cholesteatoma specimens significantly overexpressed CK17, CK13, and Ki67 when compared to normal bony EAC skin controls, while a subset showed loss of expression of 34ße12, which provides some insight into its pathogenesis.

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.

Role of Whole body PET/CT and Examination under anesthesia with multi-site biopsy in evaluating CUP.

To evaluate the role of 18FDG-WBPET-CT, Examination under anesthesia (EUA), and multiple-site biopsy in detecting the occult site in head & neck carcinoma of unknown primary (HN-CUP). In this prospective study, 22 patients with diagnosed CUP, after a thorough outpatient endoscopic evaluation of upper airway and radiological evaluation (CT/MRI) that ruled out a primary lesion were included. These patients subsequently underwent whole-body PET-CT and EUA. Based on the presence of suspicious findings ( +) or their absence (-) on 18FDG-WBPET-CT (P) and EUA (E), we divided the patients into 5 groups: P-E-, P-E + , P + E-, P + E + , and P + or E + . All these patients underwent bilateral palatine tonsillectomy, bilateral nasopharyngeal biopsy, and ipsilateral lingual tonsillectomy for identification of occult primary. Out of 22 patients, the primary could be detected in 4 patients (18%) after the workup (three in the oropharynx and one in the hypopharynx, all ipsilateral). 18FDG-PET-CT suspected primaries in 7 patients; biopsy was positive for three (sensitivity-75%, specificity-77%, PPV-43%, NPV-93%). Out of 5 patients, who had suspicious findings on EUA, 3 of the biopsies revealed malignancy (sensitivity-75%, specificity-88%, PPV-60%, NPV-94%). Both PET-CT and EUA when combined, yield a NPV of 100% if both are negative and PPV of 100% when both are positive for suspicious findings. No primary was identified in the absence of a suspicion by PET-CT or EUA. Without a suspicion on 18FDG-WBPET-CT and EUA, there is a limited role of multiple-site biopsies in patients of HN-CUP.

An Audit of the Procedure of Open Thyroidectomy at A Tertiary Care Centre.

We plan to evaluate the various variables associated with the complications of thyroidectomy performed at our department in the last 5 years. Medical records of the patients who underwent thyroidectomy during 2014-2018 were collected. Complications of hypocalcemia and recurrent laryngeal nerve palsy were analysed in terms of the demography, cytopathology and the extent of surgery. Student's t-test, Mann-Whitney U-test, Fisher exact test and chi square test were applied to look for any significant associations. P value < 0.05 was considered significant. 123 patients were analysed (87 females, 38 males). Mean age was 38.3 years (range 11-71 years). Most common cytopathology was papillary carcinoma thyroid (Bethesda VI) - 43/123 (35%). 107 of these 123 patients underwent primary surgery, 10 underwent revision surgery while 6 underwent completion thyroidectomy. Seven patients incurred RLN palsy out of which 3 were temporary. RLN palsy was seen in only malignant cases (p < 0.05). Incidence was higher in T4a stage (p < 0.05). However, it had no association with a simultaneous central or lateral neck dissection. Hypocalcemia was seen in 22 patients (17.8%), out of whom 9 patients developed permanent hypocalcemia. It was seen significantly higher in patients undergoing central neck dissection (p < 0.05) and in malignant thyroid lesions (p < 0.05). Gender, age and the cytopathology had no bearing on RLN palsy and hypoparathyroidism. Malignant thyroid lesions had a significantly higher incidence of RLN palsy and hypoparathyroidism. A thorough anatomical knowledge can reduce the incidence of these complications.

Prognostication of Sino-Nasal Mucormycosis.

Introduction: For the purpose of prognostication of sinonasal mucormycosis, a detailed analysis of the clinical, diagnostic, therapeutic and outcome parameters has been contemplated. Materials and Methods: Retrospectively data was collected for all patients of sinonasal mucormycosis managed in a tertiary care hospital in last 5years. Results: Diabetes was the commonest comorbidity among total of 52 cases. Disease extent-wise, 16, 23 and 13 patients had sino-nasal (SN), rhino-orbital (RO) and rhino-orbito-cerebral (ROC) mucormycosis respectively. Median cumulative Amphotericin-B administered was 3.5gms and 94.2% of cases underwent surgical debridement depending on the disease extent. With a median follow-up of 18months, 67% of the patients are alive and disease free, 2% are under treatment and 29% of patients have expired. The mortality rate was 12.5% in SN, 30.5% in RO and 38.5% in ROC mucormycosis. Palatal and orbital involvement is associated with statistically significant mortality risk at one month. Conclusions: Mortality rate in sino-nasal mucormycosis can be significantly curtailed with prompt control of underlying comorbidity, aggressive medical and adequate surgical management.

Management of Allergic Fungal Rhinosinusitis Associated with Vision Loss During COVID-19 Era.

The ongoing COVID-19 pandemic has given rise to unique challenges related to healthcare management. The problems have arisen due to the direct effect of COVID 19 infection and treatment or as repercussions of administrative efforts being undertaken to check the rapid spread of the epidemic. The management of some of the diseases has been hampered with the implementation of the policies like lockdown and transportation difficulties. This paper presents a series of four patients (6 eyes with vision loss) of an otherwise benign entity, Allergic Fungal Rhinosinusitis (AFRS), causing visual deterioration, managed amid the pandemic. AFRS has been known to cause vision loss by pressure over the optic nerve or its blood supply; however, a timely surgical intervention in the form of functional endoscopic sinus surgery to remove the disease and decompress the optic nerve, results in favourable outcomes in most patients. A delay in diagnosis and treatment may result in irreparable damage with the resulting inability to salvage the vision. In our series, we observed that vision recovery could be achieved in 66.7% of the affected eyes (four out of six eyes), while a poor visual outcome was observed in two (33%). The poor visual outcome was observed for the eyes with a prolonged visual impairment (4-6 months) at the time of presentation. We would appeal to the physicians to be cognizant of the adverse outcomes associated with the delayed surgical intervention of AFRS in the current pandemic scenario.

Outcomes of Tracheostomy in COVID-19 Patients: A Single Centre Experience.

The rapid emergence of COVID-19 has led to increase in the number of patients requiring prolonged ventilation and tracheostomy. Though global guidelines are evolving, there is a paucity of literature about optimal timing and outcome after tracheostomy in COVID-19 patients. We set out to assess the clinical characteristics and outcome of COVID-19 patients who underwent tracheostomy.This single-center, prospective observational cohort study analyzed all the consecutive tracheostomy performed on COVID-19 patients from April 1 2020 to January 31, 2021. The primary outcome measure was the 30-day mortality rate following tracheostomy and association with various prognostic risk factors. The secondary outcome measures included various tracheostomy-related events, perioperative complications, and decannulation rate.The study included 51 patients with a median age of 52 years and the majority were male (62.74%). 62.74% (32 of 51) tracheostomies were done early (within 10 days of intubation) and the mean duration from endotracheal intubation to tracheostomy was 10.27 days. The 30-day mortality rate was 66.66% (34 of 51) with no tracheostomy-related mortality and the mean duration between tracheostomy and death was 8.29 days. The presence of sepsis was associated with a higher rate of mortality (p = 0.002) while the timing of tracheostomy was not related to increased mortality (p = 0.365). The most common perioperative complication was tracheostoma bleeding (16.64%). At a median follow-up of 7.5 months, only four patients were decannulated.Though associated with a higher rate of 30-day mortality rate, tracheostomy among COVID-19 patients is a safe and an effective weaning tool.

A Pilot Study Comparing Teletherapy with the Conventional Face-to-Face Therapy for Speech-Language Disorders.

ABSTRACT: Speech-language therapists along with affected individuals face various challenges for accomplishing the rehabilitation services. In the current COVID19 pandemic scenario, telerehabilitation has emerged as a substitute to the traditional face-to-face therapy, and is the only option possible in some cases. To subjectively assess the feasibility & acceptability of telerehabilitation provided by speech-language pathologist to patients of speech and language disorders. This qualitative study includes 20 patients suffering from disorders of fluency, voice, swallowing and neurogenic disorders. The participants included were undergoing face-to-face therapy at our institute. After the completion of face-to-face session series, telerehabilitation services were provided through a video calling app. The outcomes of teletherapy were assessed subjectively using a structured questionnaire on 11 parameters using a Likert scale. Of the included 20 patients, after completion of teletherapy, four patients chose the physical interaction as the preferred mode of therapy while 16 chose teletherapy as the preferred mode. Except three clients who rated their overall satisfaction as '3', others rated as '4' or '5'.The therapists were satisfied with the outcomes in 17 cases, and were pleased with the overall progress of all the clients (rated 4 or 5). Telerehabilitation is a reliable method to deliver speech and language services at community level, on long-term basis, as is proven by the high satisfaction scores among the clients as well as the service providers. CLINICAL TRIAL REGISTRATION: The trial has been registered in Clinical Trials Registry of India (CTRI) vide number CTRI/2018/04/ 012,922 (http://ctri.nic.in/Clinicaltrials/login.php) on 02/04/2018.

Chloroquine nasal drops in asymptomatic & mild COVID-19: An exploratory randomized clinical trial.

Background & objectives: Chloroquine (CQN) administered as nasal drops has the potential to achieve much greater local tissue levels than with oral/systemic administration. This trial was undertaken to study the efficacy and safety profile of topical nasal administration of CQN drops in reducing viral load and preventing clinical progression in early COVID-19 infection. Methods: This randomized clinical trial was done with a sample size of 60. Reverse transcription-polymerase chain reaction (RT-PCR) confirmed asymptomatic patients or those with mild COVID-19 illness [National Early Warning Score (NEWS) ≤4] were included. Patients were randomized in a 1:1 manner. Control arm (standard supportive treatment, n=30) was compared with intervention arm (n=30) of standard treatment plus CQN eye drops (0.03%) repurposed as nasal drops administered six times daily (0.5 ml/dose) for 10 days. Outcome measures were adverse events and adherence; clinical progression and outcomes were measured by NEWS; sequential RT-PCR cycle threshold (Ct) values were also noted on days 0, 3, 7 and 10. Results: Nasal CQN was associated with local irritation in seven and non-compliance in one of 30 patients. Eleven patients were excluded due to enrolment error (2 - recovered; 9 - false-positive referral), and 49 patients were analyzed as per modified intention-to-treat analysis. Clinical recovery was noted as similar with 100 per cent asymptomatic by day seven in both arms. Virological outcomes also indicated similarly improving Ct values in both arms, and similar proportion of patients transitioning to non-infectivity by day 10 (controls - 19/25; nasal CQN - 15/24). Nine false-positive patients with enrolment error and day 0 RT-PCR negative were initially uninfected but had continuing COVID-19 exposure and treatment as per randomization. Patients receiving nasal CQN (n=5) demonstrated stable Ct values from day 0 to 10, while patients with no nasal CQN (n=4) demonstrated significant dip in Ct value indicating to infection (Ct<35) and infectivity (Ct<33). Interpretation & conclusions: The present study suggests to the potential of topical nasal CQN in the prevention of COVID-19 infection if administered before the infection is established. No significant differences in clinical or virological outcome were however, demonstrated in patients with mild but established illness.

Application of the new SMS system of cochleovestibular anomalies: our experience with nine cases of type III anomaly.

OBJECTIVE: To present and analyse the radiological findings, surgical findings, pre-implantation and post-implantation speech and hearing outcomes of nine children with SMS Type III cochleovestibular malformation. STUDY DESIGN: Retrospective case series of nine children with pre-lingual profound sensorineural hearing loss who underwent cochlear implantation (Jan 2012 to July 2019). These children had been classified as Type III malformation according to the SMS Classification of cochleovestibular anomalies. Facial nerve anomalies, CSF leaks and any other significant surgical finding were noted. Meaningful Auditory Integration Scale (MAIS) was used to report the child's pre-operative and two-year post-implantation auditory and speech abilities. Any significant improvement was assessed using the Wilcoxon signed rank test. P value < 0.05 was considered significant. RESULTS: Out of nine patients, five patients sustained CSF gushers, while three patients had mild CSF leak, which were plugged adequately. No facial nerve anomalies were encountered. Post-op course was uneventful for all nine patients. MAIS scores at a two-year follow-up showed significant statistical improvement (P < 0.05) when compared to pre-operative scores. CONCLUSION: Cochlear implant is the treatment of choice for children with type III cochleovestibular malformation. There are significant auditory and speech improvements expected. However, the surgeon should bear in mind the risk of CSF leak and subsequent meningitis.