A Prospective Randomised Comparative Study Between Cartilage and Fascia Tympanoplasty in a Tertiary Care Hospital to Look for Better Alternative in High Risk Cases.

Introduction: CSOM patients are most commonly managed surgically by type I tympanoplasty using either cartilage shield technique or underlay grafting technique. In our study, we have compared the graft uptake and hearing results of type I tympanoplasty using temporalis fascia and cartilage shield, and also reviewed the literature regarding the results of these two methods. Materials and Methods: 160 patients aged between 15 and 60 years were randomized into two groups of 80 patients each, with odd numbers subjected to conchal or tragal cartilage shield grafting in group I, while in group II with even numbers, the patients underwent temporalis fascia grafting by underlay technique. Results: Three months post-surgery, the graft uptake was seen in 76 patients (95%) in the cartilage shield group as compared to 58 patients (72.5%) in the temporalis fascia group, which was statistically significant between the two groups [Fisher's exact value = 0.000]. The uptake rate was much higher in cartilage shield graft as compared to fascia graft even in complicated cases like revision tympanoplasty (TP), discharging ear, subtotal perforation and retracted/adhered TP. Also, the hearing improvement in fascia and cartilage shield group was not statistically significant comparing pre- and post-operative patients, indicating that there was not much difference in audiological outcomes between the two groups. Conclusion: We advocate the use of cartilage shield graft as a substitute for fascia graft in all feasible cases as well as in complicated situations to improve the success rate of type I tympanoplasty, without compromising on the hearing improvement, as seen in our study. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03175-1.

COVID-19-associated Mucormycosis: A clinico-epidemiological study.

BACKGROUND: There was an unprecedented increase in COVID-19-associated-Mucormycosis (CAM) cases during the second pandemic wave in India. METHODS: This observational study was done to know the epidemiological profile of CAM cases andincluded all patients admitted with mucormycosis between May 2021 and July 2021. RESULTS: Out of the enrolled 208 CAM cases (either SARS-CoV-2 RT-PCR or serology positive), 204, three and one had rhino-orbital-cerebral, pulmonary and gastrointestinal mucormycosis, respectively. 95.7 % of the patients had diabetes, out of which 42.3 % were recently diagnosed. Mean HbA1c was 10.16 ± 2.56 %. 82.5 % of the patients were unvaccinated. During their COVID-19 illness, 86.5 % were prescribed antibiotics, 84.6 % zinc preparations, 76.4 % ivermectin, and 64.9 % steroids, while only 39.5 % required oxygen therapy. The frequency of blood groups A, B, O and AB in our CAM patients was 29.5 %, 18.9 %, 38.9 % &12.6 %, respectively. At three months follow up, 60 (28.8 %) patients died, four (1.9 %) stopped antifungal treatment, and 144(69.23 %) were on antifungal treatment. 55 % (n = 33) of deaths occurred within 15 days of admission. Mortality was significantly associated with higher age, RT-PCR positive for SARS-CoV-2, raised serum creatinine and alkaline phosphatase during treatment. At 6 months follow-up, eight more patients died, three due to chronic kidney disease, four patients who had stopped treatment and one patient who was on a ventilator due to COVID-19 associated pneumonia and the rest 140(67.3 %) survived. CONCLUSION: Uncontrolled hyperglycemia, SARS-CoV-2 infection, rampant use of antibiotics, zinc supplementation and steroids were some of the risk factors for mucormycosis. Despite the overwhelming number of patients with an uncommon disease like mucormycosis, the six months mortality was much lower than expected.

The Pathogenetic Dilemma of Post-COVID-19 Mucormycosis in India.

There has been a surge of mucormycosis cases in India in the wake of the second wave of COVID-19 with more than 40000 cases reported. Mucormycosis in patients of COVID-19 in India is at variance to other countries where Aspergillus, Pneumocystis, and Candida have been reported to be the major secondary fungal pathogens. We discuss the probable causes of the mucormycosis epidemic in India. Whereas dysglycaemia and inappropriate steroid use have been widely suggested as tentative reasons, we explore other biological, iatrogenic, and environmental factors. The likelihood of a two-hit pathogenesis remains strong. We propose that COVID-19 itself provides the predisposition to invasive mucormycosis (first hit), through upregulation of GRP78 and downregulation of spleen tyrosine kinase involved in anti-fungal defense, as also through inhibition of CD8+ T-cell mediated immunity. The other iatrogenic and environmental factors may provide the second hit which may have resulted in the surge.

Case Report: Rhino-orbital Mucormycosis Related to COVID-19: A Case Series Exploring Risk Factors.

There has been a surge of rhino-orbital mucormycosis cases in India in the wake of the second wave of the COVID-19 pandemic. It has been widely suggested that dysglycemia resulting from diabetes which is a common comorbidity in COVID-19 patients, and indiscriminate steroid use has resulted in this surge. We report a series of 13 cases of rhino-orbital mucormycosis in COVID-19 patients admitted to our center between mid-April and early June 2021. The cases showed a male preponderance, two patients had loss of vision, and four of them showed intracranial extension of disease. Twelve patients had received steroids and 12 had preexisting or newly diagnosed diabetes, both steroid use and diabetes being the most common identified risk factors. Considering other possible risk factors, immunosuppressed state, antiviral or ayurvedic (Indian traditional) medications, and oxygen therapy were not associated with a definite risk of mucormycosis, because they were not present uniformly in the patients. We propose that COVID-19 itself, through molecular mechanisms, predisposes to mucormycosis, with other factors such as dysglycemia or steroid use increasing the risk.

Epoxyazadiradione exhibit activities in head and neck squamous cell carcinoma by targeting multiple pathways.

The head and neck squamous cell carcinoma (HNSCC) constitute about 90% of all head and neck cancers. HNSCC falls in the top 10 cancers in men globally. Epoxyazadiradione (EPA) and Azadiradione (AZA) are the limonoids derived from the medicinal plant Azadirachta indica (popularly known as Neem). Whether or not the limonoids exhibit activities against HNSCC and the associated mechanism remains elusive. Herein, we demonstrate that EPA exhibits stronger activity in HNSCC in comparison to AZA. The limonoids obeyed the Lipinski's rule of 5. EPA exhibited activities in a variety of HNSCC lines like suppression of the proliferation and the induction of apoptosis. The limonoid suppressed the level of proteins associated with anti-apoptosis (survivin, Bcl-2, Bcl-xL), proliferation (cyclin D1), and invasion (MMP-9). Further, the expression of proapoptotic Bax and caspase-9 cleavage was induced by the limonoid. Exposure of EPA induced reactive oxygen species (ROS) generation in the FaDu cells. N-acetyl-L-cysteine (ROS scavenger) abrogated the down-regulation of tumorigenic proteins caused by EPA exposure. EPA induced NOX-5 while suppressing the expression of programmed death-ligand 1 (PD-L1). Further, hydrogen peroxide induced NF-κB-p65 nuclear translocation and EPA inhibited the translocation. Finally, EPA modulated the expression of lncRNAs in HNSCC lines. Overall, these results have shown that EPA exhibit activities against HNSCC by targeting multiple cancer related signalling molecules. Currently, we are evaluating the efficacy of this molecule in mice models.

A radiobiological and dosimetrical comparison between simultaneous integrated and sequential boost intensity-modulated arc treatment of locally advanced head-and-neck cancer.

PURPOSE: The study aimed to compare the radiobiological and dosimetric parameters between sequential boost (SEQB) and simultaneous integrated boost (SIB) treatment regimen using intensity-modulated arc therapy technique in locally advanced head-and-neck cancer (LAHNC) patients. MATERIALS AND METHODS: A total of 24 previously untreated LAHNC patients were randomized into SIB (n= 11) and SEQB (n = 13) arms. The planning computed tomography data set was transferred to the treatment planning system. All the target volumes and organ at risk volumes were delineated. Single plan for SIB group and three plans (three phases) were generated for SEQB group of patients. Radiobiological and dosimetric parameters were compared. RESULTS: The BED10(planned) value for high-risk (HR) planning target volume (PTV) was same in both groups, whereas for intermediate-risk (IR) PTV and low-risk (LR) PTV, the values were higher in SEQB arm than SIB arm. The V95 values were 100% for all the target volumes in both arms of patients. The average D100 value for gross target volume, HR PTV, and IR PTV was higher in SEQB arm than that in the SIB arm. The average D100 value for LR PTV was higher in the SIB arm compared to that of the SEQB arm. The BED10(achieved) was calculated using D100 values of target volumes. The difference of BED10(achieved) values between SEQB arm and SIB arm further increased than the BED10(planned) values for all target volumes. The maximum doses for spinal cord, spinal cord planning risk volume, and brain stem were within the tolerance dose in both groups of patients. The left and right parotid glands sparing was comparable in both groups of patients. Average integral dose was higher in the SIB group than SEQB group. The average total monitor unit per fraction was higher in the SEQB arm than that in the SIB arm. CONCLUSION: SIB regimen may be considered as more logical and efficient over SEQB regimen in the treatment of LAHNC with comparable radiobiological and dosimetric parameters.

Papillary tumor of pineal region with an unusual clinical presentation: Case report and review of the literature.

Papillary tumor of the pineal region (PTPR) is a newly described entity, which has been recently included in the World Health Organization classification of central nervous system tumors. We report an unusual presentation of PTPR in a 17-year-old girl, which was extending into the third ventricle, along with a detailed description of morphological and immunohistochemical characteristics of PTPRs. The diagnosis of PTPR was established on immunohistopathological examination.

Ultrathin Silicon Sheet in the Management of Unilateral Post-traumatic Temporo-Mandibuar Joint Ankylosis in Children: A Good Alternative to Conventional Techniques.

We have described a new technique of using ultra-thin silicon sheet (0.2 mm) between two transected bony ends for temporo-mandibular joint (TMJ) ankylosis in children with advantages of short operative time, minimal foreign material insertion and faster recovery time post-operatively which makes our technique a good alternative to conventional techniques. Our study is a non-randomized prospective study conducted on 10 children aged between 4 and 15 years who presented to our tertiary care institute with severe trismus after traumatic injury and were willing to undergo this new technique. The main outcome measure taken into consideration was difference between pre-operative, intra-operative (on table) and post-operative mouth opening (minimum 2 years follow-up). The pre-operative mouth opening in our cases varied from 1 to 5 mm. The intra-operative mouth opening achieved ranged from 2.8 to 3.2 cm. The mouth opening was about more than 2.7 cm in all our cases at 2 years of follow-up. Our technique is a good alternative to conventional techniques used for TMJ ankylosis in children but few more randomized controlled trials are required to assess its effectiveness in comparison to conventional techniques and for universal adoption of this technique.

Lemierre's Syndrome presenting with neurological and pulmonary symptoms: Case report and review of the literature.

Lemierre's Syndrome (LS) is a potentially life-threatening condition, characterized by clinical or radiologic evidence of internal jugular vein thrombosis following an oropharyngeal infection, most commonly by Fusobacterium necrophorum. A high index of suspicion and early recognition is important for successful management and to prevent systemic complications like multiorgan failure with extremely high morbidity, prolonged hospitalization and, not uncommonly, death. We are reporting a rare case of LS that was complicated with internal jugular vein and cavernous sinus thrombosis along with lung metastatic lesions, which was diagnosed and treated at our institute.

Sinonasal undifferentiated carcinoma presenting as recurrent fronto-ethmoidal pyomucocele.

We describe a case of a 53-year-old man presented to our ENT OPD with chief complaints of recurrent right supraorbital swelling for last 6 months, which was associated with bilateral periorbital edema. Contrast-enhanced computerized tomographic scan showed a large frontoethmoidal mucocele with expansion of the bone but there was no erosion. Endoscopic marsupialization along with external frontoethmoidectomy was done to treat the patient and the collected pus, fluid and necrotic tissue was sent for HPE. Biopsy came out to be sinonasal carcinoma, which is a rare occurrence in frontal sinus. Moreover, sinonasal carcinoma presenting as recurrent frontoethmoidal mucocele has not been reported till date in the literature to the best of our knowledge. This case is being reported to make aware among all ENT surgeons and to be cautious about such presentation.

S-shaped tracheostoma in pediatric tracheostomy using three-dimensional sigma-plasty--a novel technique to possibly reduce procedure related complications.

OBJECTIVES: We have designed a technique of tracheostomy in pediatric patients with S-shaped incision on the tracheal wall which we think, provides a larger cross-sectional area of stoma and facilitates easier insertion of tracheostomy tube and thus helped in reducing early and late complications associated with it in our series. TECHNIQUE: The trachea was exposed in midline by a vertical skin incision. In order to make S-shaped tracheostoma, second tracheal ring was identified. The conventional vertical incision was made in second tracheal ring and then extended at both its ends laterally in the inter-cartilaginous space parallel to the tracheal cartilage in the opposite direction to make the incision S-shaped. The trachea was dilated with tracheal dilator and appropriate size of tracheostomy tube was then placed into the trachea. RESULTS: S-shaped tracheostomy was performed in 40 children with mean age of 6.36 years (age range is 2-12) required for airway maintenance or prolonged ventilatory support. The incidence of early complications was quite less in our patients (ranged from 0 to 5%). There was no incidence of excessive intra-operative bleeding or injury to surrounding structures causing subcutaneous emphysema or vocal cord palsy. One patient developing pneumothorax after the procedure was managed conservatively. There was no incidence of tracheo-esophageal fistula, suprastomal collapse or difficulty in decannulation on 9 months of follow up related to our technique. However, one of the patients developed early trachietis and cutaneous peristomal granulomas and 2 patients developed late trachietis which was treated conservatively. CONCLUSION: S-shaped tracheoplasty, a new pediatric tracheotomy technique has resulted in a quantifiable reduction in the risk of the early and late complications in our series. Hence, we feel that this new technique is a better alternative to existing methods but larger randomized controlled studies are required before universal adoption of this technique.

Frontal sinus mucocele with orbital complications: Management by varied surgical approaches.

A mucocele of a para-nasal sinus is an accumulation of mucoid secretion and desqua-mated epithelium within the sinus with distension of its walls and is regarded as a cyst like expansile and destructive lesion. If the cyst invades the adjacent orbit and continues to expand within the orbital cavity, the mass may mimic the behavior of many benign growths primary in the orbit. The frontal sinus is most commonly involved, whereas sphenoid, ethmoid, and maxillary mucoceles are rare. Floor of frontal sinus is shared with the superior orbital wall which explains the early displacement of orbit in enlarging frontal mucoceles. Frontal sinus mucoceles are prone to recurrences if not managed adequately. Here, we are evaluating different approaches used to manage various stages of frontal mucoceles which presented to us with orbital complications. Three cases of frontal sinus mucocele are discussed which presented to our OPD with different clinical symptoms and all cases were managed by different surgical approaches according to their severity. We also concluded that it is prudent to collaborate with the neurosurgeons for adequate management of such complex mucoceles by a craniotomy approach.

Safety profile of bone marrow mononuclear stem cells in the rehabilitation of patients with posttraumatic facial nerve paralysis-a novel modality (phase one trial).

Objectives The objectives of this study were to study the safety profile and role of mononuclear stem cells in the rehabilitation of posttraumatic facial nerve paralysis not improving with conventional treatment. Study Design This is a prospective nonrandomized controlled trial. Study Setting This study is conducted at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh between July, 2007 and December, 2008. Patients We included eight patients of either sex aged between 18 and 60 years of posttraumatic facial nerve paralysis not improving with conventional treatment presented to PGIMER, Chandigarh between July 2007 and December 2008. Methods All patients underwent preoperative electroneuronography (ENoG), clinical photography, and high-resolution computed tomography (HRCT) temporal bone. All patients then underwent facial nerve decompression and stem cell implantation. Stem cells processing was done in well-equipped bone marrow laboratory. Postoperatively, all patients underwent repeat ENoG and clinical photography at 3 and 6 months to assess for objective and clinical improvement. Clinical improvement was graded according to modified House-Brackmann grading system. Intervention Done All patients of posttraumatic facial nerve paralysis who were not improving with conventional surgical treatment were subjected to facial nerve decompression and stem cell implantation. Main Outcome Measures All patients who were subjected to stem cell implantation were followed up for 6 months to assess for any adverse effects of stem cell therapy on human beings; no adverse effects were seen in any of our patients after more than 6 months of follow-up. Results Majority of the patients were male, with motor vehicle accidents as the most common cause of injury in our series. Majority had longitudinal fractures on HRCT temporal bone. The significant improvement in ENoG amplitude was seen between preoperative and postoperative amplitudes on involved side which was statistically significant (0.041). Clinical improvement seen was statistically significant both for eye closure (p < 0.010) and for deviation of angle of mouth (p < 0.008) at 6-month follow-up in 85% of our patients, far better than the results of previous conventional surgeries. Conclusion Stem cell therapy can be used safely in human beings without any adverse effects on humans, and it appears to be a promising modality for rehabilitation of patients with posttraumatic facial nerve paralysis not improving with conventional surgical treatment but few more clinical series are required for validation.

Esthesioneuroblastoma presenting with proptosis and bilateral neck metastasis: An unusual presentation.

Esthesioneuroblastoma (ENB) presenting simultaneously with proptosis and bilateral neck metastasis is a very rare presentation. ENB is a rare tumor arising from the olfactory epithelium of the nasal vault which frequently invades the cranial base, cranial vault and orbit. ENB has a bimodal age distribution between 11 and 20 years and between 51 and 60 years. ENB accounts for approximately 1 to 5% of intranasal cancers and no consensus has been reached yet regarding the treatment of this tumor. We are reporting a 17-year-old male patient who presented with right eye proptosis with loss of vision and bilateral neck metastasis. Contrast enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) was done which showed Kadish stage C tumor. Nasal biopsy was done to make the diagnosis and the patient was subjected to radiotherapy. Tumor responded to radiotherapy and both the primary lesion and the cervical lymph node metastasis disappeared. The purpose of this study is to report the rare presentation of proptosis along with bilateral cervical lymph node metastasis in this rare sinonasal tumor.