COVID Induced Functional Exhaustion and Persistently Reduced Lymphocytes as Vital Contributing Factors for Post-COVID Rhino-orbital and Cerebral Mucormycosis in Patients with Diabetes: Report from the Indian Sub-continent.

The current pandemic of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is a global, unanticipated public health crisis. Another emerging challenge is the prevalence of "black fungus", or mucormycosis, among patients who recovered from COVID-19 infection. A retrospective study was conducted on 12 patients in a post-COVID recovery phase who developed mucormycosis. The study parameters evaluated lymphocyte count, CD4+ T cell status, and associated systemic co-morbidities for the patient, namely diabetes. The interventions during the treatment for COVID were also recorded to include administration of oxygen, ventilator assistance (invasive and non-invasive)/oxygen support, and steroid use. The possible relationship between low lymphocyte and CD4+ counts with diabetes and fungal growth was evaluated. It was observed that the majority of the patients who had a positive history for diabetes with low lymphocyte and CD4+ counts were more susceptible to opportunistic fungal infections. Most of the patients, but not all, had a history of receiving oxygen or assisted ventilation, as well as steroids, during the treatment for COVID infection. These interventions may be considered as accessory contributing factors for fungal infection. Post-exposure to SARS-CoV-2, therapies should be targeted at prevention of functional exhaustion of lymphocytes and maintaining optimal lymphocyte and subset counts in susceptible hosts for the prevention of opportunistic fungal infections. The relationship between functional exhaustion of the lymphocyte, diabetes, and COVID mandates further research.

A Simplified Single-Penetration Technique of IANB (MK Technique) for Mandibular Anesthesia.

INTRODUCTION: Owing to the anatomical basis established on the detailed course, distribution and innervations of buccal nerve in the literature, we believe that an effective and extensive buccal nerve block could be achieved when the nerve is anesthetized proximal to its branching point which relates to anteromedial aspect of ramus (retromolar fossa). Though several techniques of inferior alveolar nerve block (IANB) including few single-penetration approaches were already well reviewed and practiced, pitfalls remained in terms of achieving adequate retromolar soft tissue anesthesia, as well as undermining the very importance of contacting the bone and the orientation of the bevel. We propose a simplified single-penetration technique aligning almost similar to conventional technique and its well-adopted landmarks, but still obviating the need for a separate penetration for long buccal nerve anesthesia. AIM: To study the efficacy of a simplified single-penetration technique for mandibular anesthesia. OBJECTIVES: To study the adequacy of the simplified IANB technique in minimizing the number of penetrations required to achieve buccal nerve anesthesia decreasing patient's pain and discomfort when IANB is performed and the ease of adaptability across the operators. MATERIALS: A 25-gauge 42-mm needle, local anesthesia with adrenaline-2% lignocaine HCl (1:80,000), 2.5-ml syringe, observation form. METHOD: Study 1-A sample size of 120 cases, in oral surgery department of our college, with 60 patients in Group I (control) where patients received anesthesia through conventional IANB and 60 patients in Group II (experimental) where patients received anesthesia through simplified IANB. Both the groups are again subdivided into group A (single operator) and group B (multiple operators). Study 2-20 bilateral mandibular impacted third molar in oral surgery department of our college, with right side (control-conventional technique) and left side (experimental-simplified single-penetration technique). VAS data are recorded in the excel sheet. RESULTS: The success rate of the simplified technique is quite comparable to the conventional groups. The mean pain and discomfort score in simplified technique was 3.08 which is relatively lower when compared to mean value in conventional technique which was 6.88. The difference was statistically significant. CONCLUSION: Simplified technique minimizes the number of penetrations, which substantially decreases patient's pain and discomfort levels not only during injection, but also during surgical procedures on mandibular posterior region because of extensive and profound buccal nerve territorial anesthesia.

Vertically unstable fractured mandibular segment with attached genial tubercles as a parameter for difficulty during intubation for general anaesthesia-substantiation with computed tomographic (CT) scan evidence.

PURPOSE: To study and evaluate the anatomic alterations in the suprahyoid musculature, the hyoid bone, and the laryngeal inlet in patients with vertically unstable fractured mandibular segment with attached genial tubercles using computer tomography for substantiation of the clinical evidence and hypothesis of difficulty during intubation for general anaesthesia. MATERIALS AND METHOD: Random sampling methodology was used to enrol patients with mandibular bilateral parasymphysis fracture qualifying for the classification of vertically unstable fractured mandibular segment with attached genial tubercles for group A patients. Patients with unilateral parasymphysis fracture with vertically stable mandibular segment were included in group B. Forty patients with parasymphysis fracture and no other associated facial fracture/injury were evaluated prospectively by comparing their pre-operative computer tomography (CT) images with post-operative CT images taken after the reduction of the fracture. Parameters evaluated were variation in the radiologic anatomy of the laryngeal inlet shape and alteration in the suprahyoid musculature after open reduction and internal fixation of the fracture when compared with pre-operative CT images. RESULTS: The following were the results/observations from this study among group A patients: (1) The distance between the genial tubercles and the hyoid was found to be reduced. (2) Dorsal bodily movement of the hyoid was observed suggesting loss of anterior hyoid support. (3) The posttraumatic changes in the shape of the laryngeal inlet were observed in cases with vertically unstable bilateral parasymphysis fracture. (4) Restoration of morphology of the laryngeal inlet and anterior-posterior distance between genium and hyoid after reduction. CONCLUSION: Computer tomographic findings confirm that the displacement of fractured mandible and resultant displacement of the genial musculature have their effect on the laryngeal morphology. These posttraumatic changes in cases with dorsally displaced vertically unstable fractured mandibular segment with attached genial tubercles should be considered as a vital parameter for assessing difficulty during intubation.

A preliminary study on plasma concentration achieved following intrapterygomandibular space injection of dexamethasone as a route of drug delivery with lignocaine inferior alveolar nerve block-correlation of clinical effects.

PURPOSE: To determine the quantity of dexamethasone plasma concentration achieved following intrapterygomandibular space injection of dexamethasone when co-administered with inferior alveolar nerve block correlating with the clinical effects in the postoperative phase. OBJECTIVE: A preliminary prospective study to evaluate the dexamethasone plasma concentration achieved following intrapterygomandibular space injection of dexamethasone with 2% lignocaine inferior alveolar nerve block to achieve hemi-mandibular anesthesia for minor oral surgical procedures and derive clinical correlations. BACKGROUND: Dexamethasone is a glucocorticoid, chiefly used for the management of postsurgical sequelae like trismus and swelling in maxillofacial surgical practice. Conventionally, parenteral dexamethasone is administered via intravenous or intramuscular route. Intrapterygomandibular space injection is a novel route of steroid delivery described in literature. For minor oral surgical procedures in maxillofacial surgical practice requiring inferior alveolar nerve block, dexamethasone can be administered along with local anesthetic through a single injection as a mixture (twin mix). METHODS: Prospective double-blind randomized clinical trial was designed to evaluative plasma concentration of dexamethasone achieved following injection of a freshly prepared mixture of 1.8 ml of 2% lignocaine with adrenaline (1:200000) and 1 ml (4 mg) dexamethasone [2.8 ml solution of twin mix] in the pterygomandibular space. The 30 candidates included for the trial were randomly split into three study groups (ten each)-(1) control group (C); (2) intramuscular group (IM); (3) intraspace group (IS). RESULTS: The mean plasma dexamethasone concentration at 30 min postinjection in group IM was 226.41 ± 48.67 ng/ml and for IS group it was 209.67 ± 88.13 ng/ml. Post hoc (Bonferroni-Holm test) intergroup comparison for plasma dexamethasone concentration (IM and IS) was found statistically insignificant (P = 0.605). CONCLUSION: Intraspace route of drug administration can be utilized to deliver dexamethasonized local anesthetics safely with predictable clinical effects in the patients requiring mandibular minor oral surgery under local anesthesia.

Improved Surgery Planning Using 3-D Printing: a Case Study.

The role of 3-D printing is presented for improved patient-specific surgery planning. Key benefits are time saved and surgery outcome. Two hard-tissue surgery models were 3-D printed, for orthopedic, pelvic surgery, and craniofacial surgery. We discuss software data conversion in computed tomography (CT)/magnetic resonance (MR) medical image for 3-D printing. 3-D printed models save time in surgery planning and help visualize complex pre-operative anatomy. Time saved in surgery planning can be as much as two thirds. In addition to improved surgery accuracy, 3-D printing presents opportunity in materials research. Other hard-tissue and soft-tissue cases in maxillofacial, abdominal, thoracic, cardiac, orthodontics, and neurosurgery are considered. We recommend using 3-D printing as standard protocol for surgery planning and for teaching surgery practices. A quick turnaround time of a 3-D printed surgery model, in improved accuracy in surgery planning, is helpful for the surgery team. It is recommended that these costs be within 20 % of the total surgery budget.

Guidelines of the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections: As Applied to Oral and Maxillofacial Clinical Practice.

PURPOSE: The purpose of this paper was to undertake a systematic review of literature on methicillin-resistant Staphylococcus aureus infections in oral and maxillofacial online data-bases and discuss the Infectious Diseases Society of America (IDSA) guidelines and its applications in maxillofacial clinical practice. MATERIALS AND METHODS: The available literature in oral and maxillofacial online databases was searched. The only inclusion criterion was to review published reports, abstracts and retrospective studies with emphasis on the treatment of clinical cases with methicillin-resistant S. aureus infections. Clinical Practice Guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant S. aureus infections in adults and children was reviewed and included in the study. RESULTS: Out of 18 articles found with the search terms "Methicillin-resistant S. aureus" and "MRSA" in the online databases 12 articles met the inclusion criteria for this study. The relevant data was extracted and tabulated. CONCLUSIONS: Conclusions were drawn and discussed based on the reviewed maxillofacial literature and the Guidelines by the IDSA.