An interesting report of COVID-19 associated mucormycosis (CAM) cases by two different species of Mucorales.

During surge of COVID-19-associated mucormycosis (CAM), we identified five cases of CAM where two different species of Mucorales were isolated. All had history of diabetes mellitus and presented with clinical features suggesting rhino-orbital mucormycosis. The patients grew different species from their nasal scraping/biopsy samples, Rhizopus arrhizus, R. homothallicus (n = 2); R. homothallicus, Lictheimia corymbifera (n = 1); R. arrhizus, Mucor spp (n = 1); and L. corymbifera, Apophysomyces variabilis (n = 1). All patients underwent surgical and medical (liposomal amphotericin B) treatment. All, except one growing A. variabilis and L. corymbifera survived. Mixed infection by more than one Mucorales in CAM is unique and warrants epidemiological investigation.

Injury to the Submandibular Duct and Secondary Fibrosis Causing Sialocele: An Unusual Complication of Submental Intubation.

Maxillofacial fractures with the nasal/skull base fractures may preclude nasotracheal intubation, and oro-tracheal intubation may obstruct surgical access. In these cases, submental intubation is a safe and well-accepted alternative, associated with low morbidity and complication rate. We report a case of one such rare complication, wherein following submental intubation, the patient presented with a sublingual sialocele, associated with dilatation of the submandibular duct with surrounding fibrosis. The secondary sublingual sialocele we encountered could have been due to errors in the technique of submental intubation. Hence, thorough knowledge of the submental and submandibular region's anatomy is important to avoid complications.

Clinicoradiological Profile of COVID-19-Associated Rhino-Orbital Cerebral Mucormycosis with a Focus on Computed Tomography: A Clinical Case Series and Review.

COVID-19-associated rhino-orbital cerebral mucormycosis (ROCM) has a rapidly evolving course with high morbidity and mortality. We describe imaging features of COVID-19-associated ROCM based on noncontrast computed tomography (NCCT). This retrospective single-center observational study included 50 patients with COVID-19 from January 1, 2021 to June 30, 2021 who subsequently developed ROCM confirmed by fungal culture studies. All patients underwent NCCT of the paranasal sinuses as the diagnostic workup. The involvement of the nasal cavity, paranasal sinuses, orbits, and intracranial cavity was identified and graded. The ethmoid sinuses were most commonly involved [right (n = 46 of 50) > left (n = 45 of 50)], followed by the maxillary, sphenoid, and frontal sinuses. Thinning and erosions of the hard palate were noted in 18% of patients (n = 9), whereas 34% (n = 17) showed dehiscence of the lamina papyracea. Retromaxillary fat stranding was noted in 68% of patients (n = 34). Severe ethmoid sinusitis was associated significantly with ipsilateral pterygopalatine fossa involvement. The extraocular muscles were involved in 64% of patients (n = 32), with 84% (n = 42) showing orbital fat stranding. Proptosis of the affected eye was seen in 66% of patients, optic nerve involvement in 52%, and irregularity of globe contour in 12% (n = 6). The cavernous sinuses were affected in 10% of patients (n = 5), with three of them having temporal infarcts. COVID-19-associated ROCM is an acute, invasive fungal disease characterized by multisinus involvement, often with orbital and intracranial extension. Bilateral involvement with rapid progression should alert one to underlying COVID-19 disease.

Impact of Radiotherapy on Quality of Life in T2 and Early T3 Laryngeal Carcinoma.

Objective- To acknowledge patient-perceived voice-related and overall quality of life (QOL) in addition to disability index based on the validated voice-related quality of life survey (VRQOL), WHOQOL-BREF, and WHO DAS II questionnaires in T2 and early T3 laryngeal tumors after definitive radiotherapy. Methods- 35 patients of T2(15) and early T3(20) tumors were enrolled, assessed with three questionnaires of VRQOL, WHOQOL-BREF, and WHO DAS II before the start of radiotherapy, then at 12 and 24 weeks after radiotherapy, and the results were analyzed. Results- All 35 (100%) patients had significant vocal deterioration with a raw VRQOL score of more than 25 at the beginning, which significantly improved at 12 weeks post-radiotherapy (p < 0.5). However, VRQOL scores at the 12th and 24th weeks were statistically insignificant. On comparing the WHOQOL-BREF and WHO DAS II, domains of physical health, psychological health, and participation in society showed significant improvement in both the groups after radiotherapy except distress scores in T2 laryngeal cancers, where pre and post-radiotherapy scores were not significantly different suggesting residual distress. Conclusion- The QOL parameters improve significantly with treatment, however, there exists a persistence of residual distress even at 24 weeks after radiotherapy and hence, routine involvement of clinical psychologists should be emphasized in practice to alleviate anxiety, distress, and concerns regarding disease outcome and recurrence. 12 to 24 weeks post-radiotherapy can be an optimum time to gauge the improvement in the patient-related QOL outcome parameters and does not differ much between these durations. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03397-3.

Survival Analysis of Oral Squamous Cell Carcinoma Patients Attending Tertiary Care Centre of North India.

The cumulative survival for all stages in oral squamous cell cancers (OSCC) in the world remains poor despite the advances in management; hence, we conducted this study to evaluate the survival outcomes. This is a retrospective review and analysis of treatment, follow-up and survival records of 249 OSCC patients treated in our department from April 2010 to April 2014. Telephonic interviews were conducted for survival details for some patients who had not reported. Survival analysis was done using the Kaplan-Meier analysis, comparisons were done using log-rank test and multivariate analysis was conducted using the Cox proportional hazard model to find different variables (site, age, sex, stage and treatment) affecting overall survival (OS)/disease-free survival (DFS). Two-year and 5-year DFS for OSCC were observed to be 72.3% and 58.3% with mean survival of 63.17 months (95% CI: 58.342-68.002). Similarly, OS at 2 years and 5 years were 84.3% and 55.9% with mean survival of 65.143 months (95% CI: 60.143-69.601). Tumour site, patient age, stage of disease and treatment modality had a statistically significant hazardous effect on the overall and disease-free survival rates. The significant influence of age, site of tumour, stage of disease and modality of treatment required based on the clinic-pathologic risk factors on prognosis emphasizes the importance of early diagnosis through regular screening and early treatment which can be ensured with early referral, high clinical suspicion and awareness at the point of primary/secondary care.

Oral manifestation of the monkeypox virus: a systematic review and meta-analysis.

Background: Mpox (formerly known as monkeypox) is a global public health concern, given the recent outbreaks in non-endemic countries where little scientific evidence exists on the disease epidemiology. Oral lesions among mpox cases have been poorly reported. Our aim was to estimate the overall prevalence of oral manifestations among patients with mpox globally. Methods: In this systematic review and meta-analysis, an extensive literature search in PubMed, Scopus, Web of Science, Embase, Cochrane, and preprint servers (medRxiv, arXiv, bioRxiv, BioRN, ChiRxiv, ChiRN, and SSRN) and assessment of all published articles, conducted across the world, until Nov 15 2022 as per the PROSPERO registration protocol (CRD42022371249), was undertaken. Primary studies (case series, cross-sectional, retrospective, prospective designs) that reported the oral/oropharyngeal symptoms among laboratory-confirmed mpox cases were included. The characteristics of the study, information on the number of cases, and symptomatic status were extracted from the included studies. The quality of the included studies was assessed for bias. Random-effects meta-regression with DerSimonian & Laird estimator, and subgroup analyses were conducted using STATA (v17.0). The degree of funnel plot asymmetry was assessed using Egger's test when at least 10 estimates were available. The heterogeneity between studies was assessed using the I2 statistic. The primary outcome was the pooled prevalence of oral manifestations in the examined population. Findings: 19 studies were included with 4042 laboratory-confirmed patients with mpox for qualitative and quantitative synthesis. The pooled prevalence of oral manifestations in the investigated population was 36.75% (95% confidence interval [CI]: 23.77-50.65). Heterogeneity was found to be high in the current meta-analysis (I2 = 98.24%; p < 0.001). Subgroup analysis revealed a pooled prevalence of 39.96% (95% CI: 21.42-59.91) of sore throat, 24.80% (95% CI: 8.14-46.32) of mouth sore, 18.24% (95% CI: 0.34-52.54) of tonsillitis and 17.99% (95% CI: 15.66-20.43) of mouth rash from the included studies. Interpretation: Oral manifestations are common in patients with mpox, with variations in prevalence across the sites within the oral cavity, and geography of the studies. Healthcare workers should be wary of the oral signs and symptoms of mpox in endemic and high-risk areas. Funding: None.

An Infected Third Branchial Pouch Cyst presenting with Acute Stridor in an Infant.

Branchial pouch cysts clinically mimic deep neck space infection and misdiagnosis leads to surgical drainage which can complicate into a persistently draining sinus or fistula. We present a unique case of infected third branchial pouch cyst in an infant who presented with acute stridor and our experience in its management.

Idiopathic Intracranial Hypertension and Endoscopic Optic Nerve Sheath Fenestration.

Idiopathic intracranial hypertension (IIH), also called as benign intracranial hypertension is a disorder, which is  considered benign in its course except its' ill effects on vision. Ocular findings in IIH such as papilledema, macular changes, retinal micro haemorrhages, cotton wool spots and tortuosity of vessels are the prominent features in funduscopy examination in these patients. Papilledema is a hallmark feature for evaluation of response to treatment. Ophthalmological rescue is a primary goal of management of idiopathic intracranial hypertension. Among the treatment options described in literature, optic nerve sheath fenestration is a minimally invasive endoscopic technique for the rescue of vision. We present this case-report, which will help ophthalmologists and the surgeons to determine the significance of the funduscopy changes after optic nerve sheath fenestration and help in decision making.

Our Experience with Laryngotracheal Trauma (LTT) in a Tertiary Care Centre of Western Rajasthan.

LTT is a life-threatening incident that is fortunately rare. The presenting symptoms might not correlate with the intensity of trauma and range from mild endolaryngeal edema to complete laryngotracheal transection. An early diagnosis and timely intervention is required for successful outcomes and minimizing complications. This retrospective audit was performed on 18 patients of LTT who presented to the emergency from January 2017 to December 2019. The history, clinical presentation, examination findings, degree and nature of trauma, diagnostic modalities, medical and surgical management, and outcomes were analyzed. A total of 13 males and 5 females were included in this audit, with a mean age of 38.7 years. The most common cause was accidental in 77.7% patients. 61.5% of patients presented with Schaefer grade 3 and higher. Out of which 46% underwent emergent neck exploration and repair. 27.7% (5/18) presented with sequelae which were managed either by T- tube stenting, endoscopic dilatation by coblation, or laryngotracheal resection (LTR) and end-to-end anastomosis (EEA). Out of 14 surgically reconstructed airways, successful decannulation was achieved in 57.1% (8) patients. High clinical suspicion, early referral with emergent intervention is paramount for successful outcomes, fewer recurrences, and reduction of hospital's and patient's financial burden as timely planning and intervention can ensure successful decannulation of around two thirds of the higher grades (grade 3-5) of laryngotracheal traumatic injuries. Early airway establishment is the most critical goal. Definitive treatment protocols are needed in this field which warrants further formulation of multicentric studies and audits.

Otology Training in India: Is It Up to the Mark?

Different studies have shown that a significant number of medical graduates do not achieve the necessary preparedness for delivery of effective health care in a safe and acceptable manner. Various studies have been undertaken to explore the competencies of surgical residents in otorhinolaryngology. This study was carried out to find out the status of training in otology being provided across different institutions in India. This is a cross sectional study undertaken at All India Institute of Medical Sciences (AIIMS), Jodhpur. An online survey questionnaire enquiring about different aspects of otologic training being followed at various centres was developed and was sent online to all prospective responders. Out of the 217 responders, 88 were faculty members and 129 residents. 62% of the faculty members and 56.5% of residents mentioned that their centre has a temporal bone dissection lab. 64.7% of the faculty members and 58.2% of the residents responded that temporal bone dissection is mandatory before live surgeries. 44% residents have their thesis topic related to otology. About 79% of faculty members and residents are not happy with the the training module being followed in their centre and feel it needs improvement. There needs to be a standardized curriculum that is followed all over the country for teaching the residents during their residency. Increase in existing centers with well equipped staff and facilites is required to provide the residents with opportunities to hone and refine their surgical skills during their training period. Supplementary Information: The online version contains supplementary material available at (10.1007/s12070-021-02485-0).

As the virus sowed, the fungus reaped! A comparative analysis of the clinico-epidemiological characteristics of rhino-orbital mucormycosis before and during COVID-19 pandemic.

BACKGROUND: The sudden surge of mucormycosis cases which happened during the second wave of COVID-19 pandemic was a significant public health problem in India. OBJECTIVES: The aim of this study was to analyse the clinico-epidemicological characteristics of the mucormycosis cases to determine the changes that had occurred due to COVID-19 pandemic. METHODOLOGY: A retrospective cross-sectional study was conducted at the Department of Otolaryngology Head and Neck Surgery, PGIMER, Chandigarh, India. Patients diagnosed with rhino-orbital mucormycosis were categorised into the following groups: Pre-pandemic(May 2019 to April 2020), Pandemic Pre-epidemic (May 2020 to April 2021) and Epidemic (1 May 2021 to 12 July 2021). The epidemiological, clinical and surgical data of all the patients were retrieved from the hospital records and analysed. RESULTS: The epidemic period had 370 cases, compared with 65 during pandemic period and 42 in the pre-pandemic period. Diabetes mellitus was seen in 87% of cases during epidemic period, 92.9% in the pre-pandemic period and 90.8% in the pre-pandemic pre-epidemic period. The proportion of patients suffering from vision loss, restricted extra-ocular movements, palatal ulcer and nasal obstruction was higher in the pre-epidemic groups, and the difference was significant (p, <.01). There was no history of oxygen use in 85.9% of patients and no steroid use in 76.5%. The death rates were the lowest during epidemic (10%). CONCLUSION: COVID-19 has caused a statistically significant increase in the number of mucormycosis infections. The mortality and morbidity which showed an increase during the first wave of COVID-19 decreased significantly during the epidemic period.

Tele-Otolaryngology at a Tertiary Care Center in North India During COVID-19 Pandemic Lockdown: A Validated Patient Feedback Questionnaire Based Study.

Providing medical care using the telecommunication networks holds the promise of increased access and efficiency of healthcare particularly during global emergencies like the Coronavirus disease 2019 (COVID-19) pandemic. Most of the hospital setups worldwide have put telemedicine into practice ever since the onset of the COVID-19 pandemic. This study aimed at assessing the effectiveness of Tele-otolaryngology (TO) at a tertiary care centre during the pandemic lockdown. A validated patient feedback questionnaire was developed and distributed to 2577 patients who utilised the TO mobile health service at our institute. Patient feedback-based assessment of TO effectiveness during COVID-19 lockdown was carried out. The validated questionnaire in English and Hindi was statistically robust with Cronbach's alpha value of 0.808 and 0.886 respectively. 1751 patients completed their feedback to the questionnaire. 97.5% utilised WhatsApp for TO consultation. 15.2% patients were detected of Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection with TO guidance. Up to 75% patients had a positive response to the questionnaire and 91.1% opined of savings achieved either with travel time, cost incurred or the treatment time. With respect to patient health status, 71.5% recovered, 20.1% had no change and 8.4% deteriorated with a mortality rate of 1.65%. Telehealth in otolaryngology during the COVID-19 pandemic lockdown was indispensable in managing exigencies. Redesigning of clinical protocol and technical constraints, clinician training and a validated patient feedback questionnaire would effectively bestow upon the global emergencies.

Correlation of tumour and treatment characteristics to dose received by cochlea in volumetric arc therapy.

PURPOSE: This is a radiation field simulation study using CT images designed to see the cochlear dosimetry and its correlation with tumour and treatment characteristics during radiotherapy for head and neck cancers (HNC) for identifying the factors associated with a higher dose delivered to the cochlea. METHODS: From 2018 to 2020, 80 patients with HNC underwent volumetric arc therapy (VMAT) to a dose of 66-70 Gy at 2 Gy per fraction with bilateral cochlea contoured for VMAT optimization as an organ at risk. Minimum, mean and maximum planned radiation dose to the cochlea based on tumour and treatment characteristics and dose-volume histogram variables of VMAT plans were analysed. RESULTS: Mean (standard deviation, SD) cochlear volume was 0.14 (0.06) cm3 with maximum and mean planned doses of 10.3 (SD = 11.6) Gy and 8.5 (SD = 9.8) Gy, respectively. We found a statistically significant correlation between mean dose received by bilateral cochlea (P-0.000, rright-0.84, rleft-0.78, rmidline-0.92). Tumours of the paranasal sinuses, and the parotids and more advanced T stages were associated with a higher mean dose to cochlea but was not significant statistically. The dose received by the 95% target nodal volume (D95%) showed a significant correlation with the cochlear mean dose (P-0.000, rright-0.85, rleft-0.77, rmidline-0.93) CONCLUSION: With VMAT we have achieved a better sparing of cochlea. The mean dose to the cochlea of one side significantly differed from the other side in patients with lateralized cancers. D95% of nodal volume also showed a significant correlation with the cochlear mean dose.

Severe Snoring in a Young Healthy Female: A Diagnostic Surprise.

Laryngeal Inflammatory myofibroblastic tumors or plasma cell granulomas are unusual benign lesions. Subglottic laryngeal lesions of various benign and malignant types usually present with acute or chronic stridor and respiratory obstruction features. We describe the first case in the literature where severe snoring was the presenting complaint in a patient of subglottic mass lesion with comfortable breathing during wake hour. A 28 years old female presented with loud snoring and apneic episodes during sleep for three years which showed severe Obstructive Sleep Apnoea (OSA) (AHI, Apnoea- Hypoapnoea Index: 46.5) in polysomnography (PSG) and surprisingly smooth mucosa covered subglottic mass blocking 75% of airway lumen in the laryngoscopic examination. The patient underwent tracheostomy and coblation assisted endoscopic excision, and subsequent histopathology revealed an inflammatory myofibroblastic tumour. She was later decannulated and with no features of sleep apnea post decannulation. Subglottic mass can rarely present with severe snoring and requires solid clinical suspicion for early diagnosis. Hence, subglottic lesion should be one of the differentials for atypical presentations of severe OSA.

Clinico-bacteriological and antibiotic drug resistance profile of chronic suppurative otitis media at a tertiary care hospital in Western Rajasthan.

BACKGROUND: Chronic suppurative otitis media (CSOM) is a major cause of hearing disability and morbidity in poor socioeconomic developing countries with prevalence of 4%. Indiscriminate use of antibiotics and poor follow up of patients has resulted in treatment failure, emergence of resistant strains, super infection, intra-cranial and extra-cranial complications in CSOM patients. Staphylococcus aureus, P. aeruginosa, Proteus spp. and Klebsiella spp. are most common organisms causing infection. Knowledge of microbial profile and susceptibility pattern is essential for efficacious treatment of this disorder. OBJECTIVE: To determine the clinico-bacteriological profile of CSOM, to analyze the susceptibility pattern of various antibiotics and to evaluate the in vitro efficacy of aminoglycosides over fluoroquinolones against the aerobic bacterial isolates from CSOM. METHODS: We studied 153 clinically suspected CSOM cases from March 2018 to October 2018 in Microbiology and Otorhinolaryngology department. The ear swabs were aerobically cultured and identification of the isolate was done by standard bacteriological methods. RESULTS: Safe type CSOM was a major cause of disease. Moderate (35.3%) and mild degree (32.7%) of hearing loss was seen in most of the CSOM cases. The culture positivity rate was 82.4% and the most common isolate was P. aeruginosa (55.8%) followed by S. aureus (27.5%). P. aeruginosa, A. baumannii and Enterobacteriaceae spp. showed high sensitivity to colistin, piperacillin-tazobactam, ceftazidime-tazobactam and good sensitivity for cefepime and amikacin; 33.3% S. aureus isolates were Methicillin-resistant which was sensitive to gentamicin, vancomycin and linezolid. CONCLUSION: Knowledge of the spectrum of microorganisms causing ear discharge is important for effective treatment.

Relative contributions of radiation and cisplatin-based chemotherapy to sensorineural hearing loss in head-and-neck cancer patients.

BACKGROUND: One of the debilitating complications of head and neck cancer radiotherapy is hearing loss. OBJECTIVE: To quantify the magnitude of sensory neural hearing loss (SNHL) in the head and neck cancer patients undergoing chemoradiation therapy. DESIGN AND METHODS: This is a prospective study. Eighty patients with head and neck cancers and undergoing volumetric arc therapy were taken up for the study. Regular audiological evaluation was done. The changes in audiological parameters from baseline are correlated with cochlear dose. RESULTS: Cochlea received maximum doses of up to 28.52 Gy without causing SNHL in the absence of chemotherapy. But in concurrent chemoradiotherapy, hearing loss was found at least dose of 9 Gy at frequency range of 4 KHz-8 KHz. The risk of SNHL is independent of cumulative doses of Cisplatin. In 106 ears receiving concurrent chemoradiation, 82.1% and 74.5% ears had sensorineural hearing loss at 4 KHz and 8 KHz respectively, following the completion of treatment. Otoacoustic emissions in the chemoradiation group showed a significant change at the completion of treatment. CONCLUSION AND SIGNIFICANCE: Volumetric arc therapy have facilitated sparing of cochlea (< 40 Gy). This has resulted in better clinical outcome in terms of SNHL. The inclusion of concurrent cisplatin chemotherapy is a significant risk factor for the development of SNHL at higher frequencies.