Clinical outcome of orbital apex syndrome in COVID associated mucormycosis patients in a tertiary care hospital

AIM: To share clinical pattern of presentation, the modalities of surgical intervention and the one month post-surgical outcome of rhino-orbito-mucormycosis (ROCM) cases. METHODS: All COVID associated mucormycosis (CAM) patients underwent comprehensive multidisciplinary examination by ophthalmologist, otorhinolaryngologist and physician. Patients with clinical and radiological evidence of orbital apex involvement were included in the study. Appropriate medical and surgical intervention were done to each patient. Patients were followed up one-month post intervention. RESULTS: Out of 89 CAM patients, 31 (34.8%) had orbital apex syndrome. Sixty-six (74.2%) of such patients had pre-existing diabetes mellitus, 18 (58%) patients had prior documented use of steroid use, and 55 (61.8%) had no light perception (LP) presenting vision. Blepharoptosis, proptosis, complete ophthalmoplegia were common clinical findings. Seventeen (19.1%) of such patients had variable amount of cavernous sinus involvement. Endoscopic debridement of paranasal sinuses and orbit with or without eyelid sparing limited orbital exenteration was done in most cases, 34 (38.2%) patients could retain vision in the affected eye. CONCLUSION: Orbital apex involvement in CAM patients occur very fast. It not only leads to loss of vision but also sacrifice of the eyeball, orbital contents and eyelids. Early diagnosis and prompt intervention can preserve life, vision and spare mutilating surgeries.

COVID-19 associated rhino-orbital-cerebral mucormycosis: An observational study from Eastern India, with special emphasis on neurological spectrum

AIMS

1: Describe the epidemiology and determine risk factors for COVID-19 associated mucormycosis. 2: Elaborate the clinical spectrum of Rhino-Orbital-Cerebral Mucormycosis (ROCM), pattern of neuroaxis involvement and it's radiological correlates.

METHODS

Observational study. Consecutive, confirmed cases of mucormycosis (N = 55) were included. A case of mucormycosis was defined as one who had clinical and radiological features consistent with mucormycosis along with demonstration of the fungus in tissue via KOH mount/culture/histopathological examination (HPE). Data pertaining to epidemiology, risk factors, clinico-radiological features were analysed using percentage of total cases.

RESULTS

Middle aged, diabetic males with recent COVID-19 infection were most affected. New onset upper jaw toothache was a striking observation in several cases. Among neurological manifestations headache, proptosis, vision loss, extraocular movement restriction; cavernous sinus, meningeal and parenchymal involvement were common. Stroke in ROCM followed a definitive pattern with watershed infarction.

CONCLUSIONS

New onset upper jaw toothache and loosening of teeth should prompt an immediate search for mucormycosis in backdrop of diabetic patients with recent COVID-19 disease, aiding earlier diagnosis and treatment initiation. Neuroaxis involvement was characterized by a multitude of features pertaining to involvement of optic nerve, extraocular muscles, meninges, brain parenchyma and internal carotid artery.

Assessment of Prescribing Pattern and Safety Profile of Drugs Used in Intranasal Route in Paediatric Age Group of Patients in a Tertiary Care Hospital

Background Recently there has been an increased preference for intranasal delivery of drugs due to highly vascular nasal mucosa, bypassing first pass metabolism and the blood brain barrier (BBB) lead in quick drug absorption to the systemic circulation and direct access to brain from olfactory region. For pediatric patients this route offers significant benefits over injections or oral routes, like increased compliance, easy administration, and minimal side effects. Objective Assessment of prescription pattern of drugs and safety profile of drugs used by intranasal route in paediatric age group. Method Our study was a prospective observational study paediatric age group of patients conducted in the departments of Pharmacology, Paediatrics and Otorhinolaryngology of Burdwan Medical College and Hospital, Burdwan. Data were collected in CRF and frequency distribution of collected data done. Microsoft Excel 2010 was used for analysis. Result Common age group was infants. Males were more in number. Most common indication was epistaxis. Intranasal drugs per prescription were 1.05. Most commonly prescribed intranasal drug was nasal saline. Nasal decongestant was the most common prescribed medication. Nasal drops were the most common dose formulation. Conclusion Intranasal drug prescribing in our study was mainly aimed for treating local problems, very few being for systemic action. Some prescribing indicators like prescribing by generic name and prescribing from national essential drug lists were acceptable with scope for improvement. Average number of drugs per prescription and antibiotic use was high. Adverse events after intranasal drug use were primarily local and nose related.

Intraoperative Image-Guided Retrieval of Foreign Body from Infratemporal Fossa: A Rare Case Report

Entrapped foreign bodies in the head and neck region pose a challenge for surgeons, especially when present in areas like infratemporal space. In this case report, a bomb splinter entered through skin below the right infraorbital rim, traversed the maxillary antrum and got entrapped in the infratemporal fossa of the patient, which was initially localized using preoperative two-dimensional and three-dimensional radiographs. The foreign body was exposed via Alkayat Bramley approach and finally retrieved with the help of intraoperative C-arm fluoroscopy.

Land use and land cover dynamics with special emphasis on shifting cultivation in Eastern Ghats Highlands of India using remote sensing data and GIS

Continual, historical, and accurate information about the land use/land cover (LULC) changes of the earth's surface is extremely important for sustainable management of natural resources. In this study, historical topographic sheets, IRS P6 LISS-III, and LANDSAT TM images were used to provide recent and historical LULC conditions of the Eastern Ghats Highlands of east India. The supervised classification results were further improved by employing image enhancement and visual interpretation. Ratio Vegetation Index with fuzzy-based possibilistic c-means classification approach has improved the classification accuracy of the shifting cultivated area. Post-classification comparisons of the classified images indicated that the major change consisted of barren land and forestland changing into agricultural land and scrubland. Between 1931 and 2008, forest cover was decreased from 52.7% to 29.6% of total area. There was an increase in the scrub area from 874 (10.4%) to 1269 km² (15.2%), and agricultural land from 978 (11.7%) to 2864 km² (34.2%) during the same period. The rate of deforestation was found to be 0.65 km² per year for reserve forest and 24.50 km² per year for mixed forest. The shifting cultivated area in the district was 308.7 km² during 2004, and that has been reduced since then and now is stabilized to 186.4 km² area. Among this 186.4 km² area, nearly half is covered by abandoned shifting cultivation. The decadal rate of decrease of shifting cultivated area is 0.15% per year. The shifting cultivated areas were mainly distributed at elevations 580-810 and 810-907 m and slopes 20-30 and 30-40%. Southeast and south facing slopes were preferred for shifting cultivation. Based on the identified causes of the change in shifting cultivation, policy recommendations for their better management were made.

Epidemiology of gynecological cancers in Kamrup Urban District cancer registry

BACKGROUND

Cancers of the female reproductive system - namely cancer of the cervix, corpus uteri, ovarian, vulvar, vaginal, fallopian tube cancers and choriocarcinoma are an important cause of cancer morbidity and mortality among women worldwide. It is estimated to be the third most common group of malignancies in women. The comprehensive global cancer statistics from the International Agency for Research on Cancer indicate that gynaecological cancers accounted for 20% of the 14.1 million estimated new cancer cases and 8.2 million cancer deaths among women in the world in 2012. The estimation of cancer burden is necessary to set up priorities for disease control. Gynaecological cancers have increased in India and are estimated to be around 182,602 by the year 2020 constituting about 30% of the total cancers among women in India. Among these, cancer of the uterine cervix followed by ovary and corpus uteri are the major contributors.

METHODS AND MATERIALS

Cancer is not notifiable in India, so method of collecting information on cancer was active with voluntary participation of different sources including major hospitals, diagnostic centers, state referral board and birth and death registration centers within registry area.

RESULTS

A total of 3767 (44%) cases were registered in women out of the total number of 8561 cancer cases during the period from 2010-2014. In case of gynaecological cancers a total of 661 cases of cervical, ovarian and corpus uterine cancers were registered out of the total 3767 female cancer cases (17.5%) for the year 2010-2014.The annual average crude rate in women for all sites of cancer was 117.4 per 100000 population. The corresponding AARs was 166.6.

CONCLUSIONS

Women's health issues have attained high concern in recent decades. Utmost efforts should be made to educate women in early cancer detection by creating awareness on risk factors and symptoms.

Recurrent Parotitis due to Parotid Duct Calculi

Introduction Recurrent parotitis is frequently encountered in Otolaryngology practice. Parotid calculi, however is extremely uncommon as compared to submandibular calculi. Hence parotid duct calculi as a cause of recurrent parotitis need a special emphasis. Case Report We present here a rare case of recurrent parotitis due to parotid duct calculi in a 35 yr old female patient, who initially had presented to ENT OPD with recurrent pain and swelling for last eight months. Clinical examination was suggestive of calculi in the left parotid duct area which was confirmed by relevant radiological evaluation including USG, CT scan and parotid sialography. Patient was treated by superficial parotidectomy along with removal of the calculi from the parotid duct.  Discussion Calculi arising from the submandibular duct and gland are well established and quite easy to diagnose, but parotid calculi are quite unheard of in clinical practice. According to Western literature, parotid calculi account for 15-20% of all salivary gland calculi. We present here the case along with the relevant review of the literature.

Detection of multidrug-resistant tuberculosis using MGIT™(TM) and MAS-PCR in Tripura, India

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) poses a global threat that is further compounded by the human immunodeficiency virus (HIV) epidemic.

OBJECTIVE

To detect MDR-TB among pulmonary TB (PTB) patients with or without HIV coinfection by isolating and identifying Mycobacterium tuberculosis from clinical samples and performing drug susceptibility testing (DST).

METHODS

Sputum was collected from presumed PTB cases. Microscopic examination was performed following Ziehl-Neelsen (ZN) staining and cultured in Löwenstein-Jensen (LJ) medium. First-line anti-tuberculosis DST of the isolates was performed using MGIT™ (Mycobacterial Growth Indicator Tube) and multiplex allele-specific polymerase chain reaction (MAS-PCR).

RESULTS

Of 172 study subjects, 59.3% (102/172) were smear-positive and 40.7% (70/172) were smear-negative. In the smear-positive and -negative groups, respectively 62.7% (64/102) and 8.6% (6/70) were culture-positive. DST on MGIT showed a cumulative resistance of 7.1% (5/70) to isoniazid (INH) and rifampicin. More ethambutol (EMB) and combined INH+EMB resistance was detected using MAS-PCR.

CONCLUSION

MDR-TB is a problem in Tripura, and culture and phenotypic DST are required for diagnosis. MAS-PCR may provide an alternative rapid screening tool.

Efficacy and safety of oesophageal coins removal using a Foley balloon catheter without fluoroscopic control (blind method)

Although previously reported the method is not widely used despite its significant economic advantages. We evaluate safety and efficacy of the procedure of removing coins from the upper oesophagus in children by Foley catheter without fluoroscopic control (blind method). A retrospective case series study was undertaken among 58 consecutive paediatric patients in a district level medical college hospital during the period of 2009-2010. A total of 58 cases of coins impacted in oesophagus were divided into two groups. In group A (n=27), all the impacted coins were in upper oesophagus and they were subjected to Foley catheter removaL In group B (n=31), the patients were selected for endoscopic removal under anaesthesia. Coins were successfully removed in 24 cases in group A and 28 cases in group B. The results between both the groups were compared using Chi-square test. There was no statistically significant difference (p<0.05) between the two groups. Upper oesophageal coins can be safely removed by Foley balloon catheter without fluoroscopic control. This blind technique is cost effective, avoiding the need for hospital stay and anaesthesia. It is worth trying before resorting to endoscopy.

Bilateral hamartoma of tonsils bearing ectopic teeth: a case report

Ectopic teeth presenting in bath the tonsils with hatnartomatous lesion has not been reported earlier. We present here a case of benign hamartoma of both the tonsils bearing 7 teeth in a 13 year old girl and also discuss about unusual Ectopic sites of tooth eruption as well as benign lesions of tonsil.

Three years audit of the emergency patients in the department of ENT of a rural medical college

Surgical audit is a systematic, critical analysis of the quality of surgical care provided, with the aims of improving quality of care, continuing education for surgeons, and guiding appropriate use of health resources. Emergency service is an integral part of any discipline of clinical medicine and it is considered as an indicator of quality of healthcare system. A three years record based, retrospective, cross-sectional study was carried out in the department of ear, nose and throat (ENT) of Midnapore Medical College, Paschim Medinipur,West Bengal to identify the total attendance of various emergency patients, diagnosis made thereafter, the mode of interference and outcome and the potential problems in the quality of care provided to the community. A total of 9051 patients had been admitted/attended in the ENT emergency from January 2008 to December 2010 who were included in this audit. Detailed statistical analysis of the data showed male: female (2.38:1) with the peak in the first decade of life. Majority of the patients were from Medinipur sadar (58.43%). The total otological cases were maximum (42.41%) in comparison to nose (28.98%) and throat (28.60%). The most common ear emergencies were earache due to impacted wax, acute suppurative otitis media, foreign body ear and the trauma/injury. Chronic suppurative otitis media with complications were the least. Amongst the sinonasal emergency, the most common aetiology was the epistaxis and foreign body nose in children. The different types of foreign body impaction in the throat and the inflammatory condition of throat or the inspiratory stridor due to upper airway obstruction were the main emergency situation recorded. Some cases were fatal. The overall mortality was 0.44%.

Anhidrotic ectodermal dysplasia presenting as atrophic rhinitis

Ectodermal dysplasia is a complex group of familial disorders with numerous clinical characteristics, with an incidence of 7 in 10000 born alive children. Ectodermal dysplasia affects structures of ectodermal origin like the skin and its appendages as well as other non-ectodermal structures. The most common sites of involvement are the defects in the skin, hair, teeth, nails and sweat glands,which are of ectodermal origin. Though the dermatologists and paediatricians often manage such cases, we report one case of ectodermal dysplasia presenting with atrophic rhinitis.

Fine needle aspiration cytology of thyroid nodules--evaluation of its role in diagnosis and management

Thyroid swelling is a common problem in India. Early and systematic evaluation of a nodular thyroid swelling is necessary as it is a frequent presentation of thyroid neoplasia. The objective of this study was to evaluate the efficacy of fine needle aspiration cytology (FNAC) in diagnosis and management of thyroid nodules. With the help of statistical parameters, the significance of FNAC in surgical decision making protocol has been evaluated. A comparison between final histopathological findings with initial FNAC findings is done and sensitivity, specificity, positive and negative predictive value and accuracy of FNAC is calculated and compared to already existing studies. A total of 120 cases of nodular thyroid were included, among which 12 cases were excluded from statistical analysis as they were managed conservatively. Total operated cases were 108 and study period was from November 2006 to October 2009. Analysis revealed sensitivity, specificity and accuracy of FNAC as 90%, 84.6% and 86.1% respectively. There were 12 FNAC false positive cases among which 9 were follicular neoplasm and 3 were Hurthle cell neoplasm which ultimately came as benign in histopathology. Only 3 cases of adenomatous nodule as per FNAC report proved to be papillary carcinoma on histology (ie, false negative). This study concludes that FNAC is an important diagnostic tool in early and cost effective evaluation of thyroid nodules. It helps in decision making for appropriate surgical/non-surgical management.

Chondrosarcoma of the arytenoids- a rare laryngeal malignancy

Even though laryngeal malignancies are the most frequent primary malignancies of the upper aero digestive tract except for oral cavity cancers, laryngeal chondrosarcomas are rare tumors, constituting less than 1% of all laryngeal tumors. We present a rare case of chondrosarcoma arising from the right arytenoid cartilage with sub glottic extension. The mode of presentation and management of the case is presented along with a review of the literature.

Neurofibroma of the external ear - a case report

Neurofibromas are relatively common tumours of the nervous system, but only a few cases involving the external ear have been reported. We are reporting here a case of a 20-year-old female with neurofibroma of the external ear. The primary complaint was cosmetic deformity. There was partial occlusion of the external auditory canal. The swelling was excised by postauricular approach. Surgery resulted in an excellent functional and cosmetic outcome.

Biophysical and socioeconomic characterization of a water-stressed area and simulating agri-production estimates and land use planning under normal and extreme climatic events: a case study

This study aims in linking the biophysical and socioeconomic data base layers with the technical coefficients or simulation models for agri-production estimates and land use planning under normal and extreme climatic events, and exploring the resource and inputs management options in village Shikohpur, Gurgaon district located in the northwest part of India. The socioeconomic profile of Shikohpur is highly skewed with mostly small and marginal farmers. Though the areas under wheat in Shikohpur are increasing, the productivity is declining or remaining stagnant over the years. Most of the area during kharif season (June-September) remains fallow. Pearl millet based cropping systems (pearl millet-mustard and pearl millet-wheat) are predominant. Soils are mostly loamy sand to sandy loam with average of 70-80% sand content. Organic C content in soil is less than 0.3%, due to high prevailing temperature with little rainfall and also intensive agriculture followed in this region. Though the annual average seasonal rainfall in Gurgaon did not have much variation over the years, occurrence of extreme climate events has increased in the last two decades. The crop intensity is low and the water table is declining. Water and nitrogen production functions were developed for the important crops of the region, for their subsequent use in scheduling of the inputs. InfoCrop, WTGROWS and technical coefficients were used for crop planning and resource management under climate change and its variability, extreme events, limited resource availability and crop intensification. These will help in disseminating necessary agro-advisories to the farmers so that they will be able to manipulate the inputs and agronomic management practices for sustained agricultural production under normal as well as extreme climatic conditions.

Evaluation of quantitative buffy coat (QBC) assay and polymerase chain reaction (PCR) for diagnosis of malaria

A prospective study was undertaken to compare the Polymerase Chain Reaction (PCR) and Quantitative Buffy Coat (QBC) assay with conventional Giemsa technique for diagnosis of malaria. A total of 104 samples were taken for the purpose. They comprised of fever cases suggestive of malaria (n=74) and control group, fever cases other than malaria (n=30). Peripheral blood smears were prepared by Giemsa staining and QBC assay was performed as per standard protocol. From the stored blood samples, parasite DNA was extracted and PCR was performed using P. falciparum and P. vivax specific sets of primers. The QBC assay was 100% in agreement with the Giemsa stain. Specificity of the PCR detection of P. falciparum parasites was 100%. However, sensitivity for detection of P. falciparum and P. vivax by PCR was 64.28% and 82.35% respectively. In mixed cases of malaria (n=2), PCR results were in 100% agreement with that of Giemsa. The lower sensitivity of PCR for P. falciparum could probably be due to inaccessibility of target DNA, presence of PCR inhibitors in samples and parasite strain variations.

Paraganglioma of external auditory canal

In the ear, paragangliomas are commonly found in the tympanic cavity or in juglar bulb. We, here, present a case of paraganglioma originating from the external auditory canal as it has not been reported in the world literature. The clinico-pathologic features of such a case has been described.

Latissimus dorsi muscle blood flow during synchronized contraction: implications for cardiomyoplasty

BACKGROUND

Damage in latissimus dorsi muscle flaps has been reported after clinical and experimental cardiomyoplasty, and an ischemic origin has been suggested.

METHOD

In situ, preconditioned latissimus dorsi muscles in 5 sheep were stimulated in either 1:1 (muscle: heart) or 1:2 synchrony with the systolic phase of the cardiac cycle, using a burst duration of either 21% or 35% of the cycle. Thoracodorsal artery blood flow and thoracodorsal venous lactate concentrations were measured before and immediately after a 3-minute period of stimulation.

RESULTS

The exercise-induced augmentation of thoracodorsal artery blood flow was significantly (p < 0.05) less with a 1:2 regimen than a 1:1 regimen, for both a 21% (88%; 95% confidence interval [CI], 55.6% to 127.3% versus 138.9%; CI, 97.6% to 188.8%) and 35% burst duration (123.2%; CI, 84.7% to 169.9% versus 167.0; CI, 120.8% to 222.6%). After cessation of stimulation, reactive hyperaemia was observed in 3 of 5 animals with 1:1 21% burst stimulation, and in 5 of 5 animals with a 35% burst duration, but was not seen after 1:2 regimens. A significant (p < 0.01) increase in thoracodorsal venous lactate levels was present after 1:1 35% burst stimulation (34.9%; CI, 9.9% to 65.6%), but lactate levels tended to fall when a 1:2 ratio was used (15.9%; CI, -3.2% to 31.5%; p < 0.1).

CONCLUSIONS

One-to-one stimulation regimens may be detrimental to latissimus dorsi blood flow, and an adaptive, rather than fixed, burst duration may be preferable. These findings have important implications for the cardiomyoplasty procedure.

Factors affecting the integrity of latissimus dorsi muscle grafts: implications for cardiac assistance from skeletal muscle

BACKGROUND

Severe latissimus dorsi muscle damage may compromise cardiomyoplasty performance. We analyzed factors underlying the damage produced in 20 sheep latissimus dorsi muscles by isolating the influences of electrical stimulation, mobilization (with some loss of vascular supply), loss of normal resting tension, or a combination of these.

METHODS

In group I (n = 3), the muscle was mobilized except for its neurovascular pedicle and reattached at normal resting length. In group II (n = 3), the muscle was mobilized and reattached at about 80% of resting length. Groups III (n = 6) and IV (n = 4) were as groups I and II except that continuous indirect stimulation at 2 Hz was added after 2 weeks. In group V (n = 4), the undisturbed muscle received stimulation alone. After 10 to 12 weeks, muscle samples were taken for morphometric analysis.

RESULTS

Loss of resting muscle tension appeared to be the single most damaging intervention, though mobilization and stimulation had further deleterious effects. The worst damage was seen when all three factors were combined, when 60% of the muscle cross section was occupied by connective tissue and fat. The changes were significantly more severe in the distal than in the proximal part of the muscle, implicating ischemia as a contributory factor.

CONCLUSIONS

Fiber damage reduces the effectiveness of muscle grafts used for cardiac assistance and merits further systematic investigation.

Anaesthesia for cardiomyoplasty

Cardiomyoplasty is a new surgical procedure for the treatment of severe heart failure, but early mortality has been high in the preliminary experience of many centres. This report describes the anaesthetic techniques used for the first two successful cases to be performed in the UK.