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To document changes in evaluation protocols for acute invasive fungal sinusitis during the coronavirus disease 2019 pandemic, and to analyse concordance between clinical and histopathological diagnoses based on new practice guidelines.
Protocols for the evaluation of patients with suspected acute invasive fungal sinusitis both prior and during the coronavirus disease 2019 period are described. A retrospective analysis of patients presenting with suspected acute invasive fungal sinusitis from 1 May to 30 June 2021 was conducted, with assessment of the concordance between clinical and final diagnoses.
Among 171 patients with high clinical suspicion, 160 (93.6 per cent) had a final histopathological diagnosis of invasive fungal sinusitis, concordant with the clinical diagnosis, with sensitivity of 100 per cent, positive predictive value of 93.6 per cent and negative predictive value of 100 per cent.
The study highlights a valuable screening tool with good accuracy, involving emphasis on ‘red flag’ signs in high-risk populations. This could be valuable in situations demanding the avoidance of aerosol-generating procedures and in resource-limited settings facilitating early referral to higher level care centres.
To assess the effectiveness of the nasal airflow inducing manoeuvre or ‘polite yawn’ technique in improving olfaction and quality of life in laryngectomised patients.
Using a prospective study design, 42 patients scheduled to undergo laryngectomy at a tertiary care centre were subjected to olfaction testing before surgery and two weeks following the surgery. The nasal airflow inducing manoeuvre was taught, and the olfaction test was repeated with the patient performing the nasal airflow inducing manoeuvre. Quality of life was assessed using the Appetite, Hunger and Sensory Perception questionnaire with calculation of scores after the patient had learnt the nasal airflow inducing manoeuvre.
There was a significant reduction in the composite olfaction score, from a mean (standard deviation) baseline value of 4.01 (1.39) to 0.44 (0.51), two weeks after surgery (p < 0.001). After practising the nasal airflow inducing manoeuvre, the olfaction scores increased to 3.05 (1.32) (p < 0.001). Appetite, Hunger and Sensory Perception questionnaire scores ranged from 52 to 110 (normal range, 29–145), suggesting an improvement in the quality of life of patients.
The nasal airflow inducing manoeuvre, an inexpensive, simple, patient-friendly manoeuvre, can be used in the olfaction rehabilitation of patients undergoing laryngectomy.
To determine risk factors affecting mortality in acute invasive fungal sinusitis.
This observational cohort study was conducted over a five-year period.
Of 109 recruited patients, 90 (82.6 per cent) had diabetes mellitus. Predominant fungi were zygomycetes (72.6 per cent) with Rhizopus arrhizus being most common. Of the patients, 12.8 per cent showed a positive biopsy report from radiologically normal sinuses. Factors affecting mortality on multivariate analysis were: female sex (p = 0.022), less than two weeks between symptoms and first intervention (p = 0.01), and intracranial involvement (p = 0.034). Other factors significant on univariate analysis were: peri-orbital swelling (p = 0.016), restricted ocular movements (p = 0.053), intracranial symptoms (p = 0.008), posterior disease (p = 0.058), imaging showing ocular involvement (p = 0.041), fungus being zygomycetes (p = 0.050) and post-operative cavity infection (p = 0.032). Bilateral, palatal and retromaxillary involvement were not associated with poor prognosis.
Diagnosis of acute invasive fungal sinusitis requires a high index of clinical suspicion. Recognition of factors associated with poor prognosis can help when counselling patients, and can help initiate urgent intervention by debridement and antifungal therapy. Post-operative nasal and sinus cavity care is important to reduce mortality.
This study aimed to describe the clinical presentation, microbiological profile and management of complications of bone wax usage for surgical procedures at the skull base.
The case records of a series of five patients who developed post-operative surgical site complications because of bone wax usage during skull base surgery were reviewed.
In all five patients, persistent site-specific clinical features were noted along with intra-operative presence of excessive bone wax. Three unique cases of presentation, one with a fungal brain abscess because of Aspergillus flavus infection, another with fungal osteomyelitis because of Trichosporon beigelii infection and a third with intradural migration of bone wax into the cerebellopontine angle cistern are highlighted.
The presentation of surgical site infection at the skull base because of excessive use of bone wax can be manifold. The need for testing appropriate cultures including fungal culture is highlighted.
In order to study the epidemiology of acute otitis media (AOM) and Streptococcus pneumoniae nasopharyngeal colonization in the first 2 years of life, we followed up an unvaccinated birth cohort monthly and at visits when sick, with otoscopy to detect AOM and performed nasopharyngeal swabbing to detect S. pneumoniae. Serotyping of positive cultures was also performed. Of 210 babies who were enrolled at birth, 61 (29·05%) experienced 128 episodes of AOM [relative risk 2·63, 95% confidence interval (CI) 1·21–5·75] with maximum incidence in the second half of the first year of life. Episodes ranged from 1 to 7 (mean 2·1 episodes). Most (86·9%) babies with AOM had a positive culture swab giving an odds ratio (OR) of 1·93 (95% CI 1·03–3·62, P = 0·041) for this association. Other risk factors identified for AOM were winter season (OR 3·46, 95% CI 1·56–7·30, P = 0·001), upper respiratory infection (OR 2·43, 95% CI 1·43–4·51, P = 0·005); residents of small households were less likely to develop AOM (OR 0·32, 95% CI 0·17–0·57, P < 0·01). Common S. pneumoniae serotypes isolated during episodes were 19, 6, 15, 35, 7, 23, 9 and 10 which indicated a theoretical coverage for pneumococcal vaccines PCV10 and PCV13 constituent serotypes of 62·8%. We conclude that AOM in Indian infants is often associated with S. pneumoniae colonization of the nasopharynx as well as other risk factors.
To investigate differences in orbital involvement in patients with invasive versus non-invasive fungal sinusitis.
One hundred consecutive cases of fungal sinusitis were assessed clinically and by computed tomography scan to evaluate orbital involvement.
Clinical orbital involvement was more common in invasive (73.5 per cent) than non-invasive (12.1 per cent) fungal sinusitis (p = 0.000). Computed tomography scanning showed similar orbital involvement in both groups, except for erosion of the floor of the orbit, which was more common in patients with invasive fungal sinusitis (p = 0.01). Extra-ocular muscle enlargement (44.4 vs 4 per cent, p = 0.01) and optic atrophy (44.4 vs 0 per cent, p = 0.003) were more common in chronic than acute invasive fungal sinusitis. Four patients (16 per cent) with acute invasive fungal sinusitis had no evidence of orbital involvement on scanning, despite clinical evidence of optic atrophy.
Orbital involvement is more common in invasive than non-invasive fungal sinusitis. The difference is more evident clinically than on computed tomography scanning. Patients with acute invasive fungal sinusitis may have limited evidence of orbital involvement on scanning, despite extensive clinical disease.
To highlight the clinical presentation and management of a rare case of oncogenic osteomalacia due to an ethmoid sinus tumour.
Materials and methods:
We examined the case records of a 55-year-old man who presented with progressive fatigue, weakness and bone pain, and noted the clinical presentation, laboratory investigations, computed tomography findings, operative notes and follow-up details.
Oncogenic osteomalacia secondary to a paranasal sinus neoplasm is a rare entity. The causative tumour is often occult and may be missed by routine clinical examination. This case report illustrates the appropriate pattern of evaluation and management to ensure a successful outcome.
To determine the causes of delay in diagnosis and treatment of Indian patients with vestibular schwannomas.
In a prospective study from 2003 to 2005, 50 patients with a confirmed diagnosis of vestibular schwannoma were interviewed to determine the causes for (1) the delay between the patient noting the initial symptom and the definitive diagnosis, and (2) the reasons for delayed diagnosis.
In 90 per cent of patients, the initial symptom was either hearing loss (62 per cent), vertigo (24 per cent) or tinnitus (4 per cent). However, most patients had been diagnosed and had presented for surgery only after neurological symptoms had became apparent. The delay between the initial medical consultation and the final diagnosis ranged from one month to 204 months (mean ± standard deviation, 32.2 ± 38.9 months). After the patient had noted symptoms, the diagnosis of vestibular schwannoma was delayed due to doctor-related causes in 80 per cent of cases, and due to patient-related causes in 20 per cent. Delay following diagnosis was minimal.
Delay in the diagnosis of vestibular schwannoma in Indian patients is due to both doctor- and patient-related factors.
Diagnosis of allergic fungal sinusitis (AFS) in patients who present with rhinosinusitis and polyposis is based upon certain clinical, histopathological and mycological histopathological criteria are the demonstration of fungal hyphae in allergic mucin and absence of tissue invasion in the excised polyps. Previous reports have indicated difficulty in demonstrating fungal hyphae on histological examination in up to 75 per cent of cases. Analysis of a series of 25 patients with AFS, suggested methods to ensure demonstration of fungal hyphae and thus increase diagnostic yield in cases with suspected AFS. criteria. Specific diagnostic
In order to determine whether selection of autograft ossicles in cholesteatomatous ear disease should be based on upon their apperance under the surgical operating microscope, we studied the histopathological features of 113 such ossicles. We attempted to correlate the extent of erosion of the ossicle, as noted under the surgical operating microscope, with their histopathological apperance. There were 60 mallei and 53 incudes. Seventy-nine ossicles were eroded and 34 were intact. The commonest abnormality noted was erosion of the long process of the incus (75 per cent). Both intact and eroded ossicles had similar histological features. There was no evidence of intra-ossicular cholesteatoma. The results suggest that the extent of erosion of these ossicles as seen under the surgical operating microscope should in no wasy prejudice their use as autografts when required.
The records of 94 consecutive developmentally retarded children with speech retardation and suspected hearing loss who underwent auditory assessment by both conventional behavioural observation audiometry (BOA) and brain stem evoked response audiometry (BERA) were analysed. In 54 children (57.4 percent) there was good agreement between the results of both techniques leading to a clearcut diagnosis. In 22 children a diagnosis was possible only by the results of BERA as the results of BOA were inconclusive. Of the remaining 18 children, two groups could be identified whose results posed a dilemma. Group 1 (n = 7) consisted of children whose BOA test results differed considerably from their BERA results. Group 2 (n = 11) consisted of children in whom there was no discernible response by BERA while the response by BOA was either inconsistent (n = 5) or not elicitable (n = 6). The specific strategies to be adopted for hearing assessment in these situations are discussed.
A retrospective analysis of thirty patients with external laryngeal trauma was performed to assess the type and extent of injuries commonly seen as well as the outcome following treatment. Outcome was assessed both in terms of voice and airway. Major laryngeal injuries (19 cases) outnumbered minor injuries (11 cases). A good correlation exists between the symptoms of haemoptysis and stridor at presentation and severity of the injury (p = 0.002). Early surgical intervention is associated with better outcome (p = 0.01). However there is no statistically significant difference in outcome between major and minor injuries (p = 0.3) indicating that other factors are operative in determining outcome. Based on our findings a management strategy for patients with external laryngeal trauma is outlined.
Laryngeal tuberculosis is one of the rarer forms of extrapulmonary tuberculosis. A retrospective analysis of 26 patients seen in the last nine years in our hospital was conducted to illustrate the various modes of clinical presentation. Of the 26 patients, twenty were male and six female. The average age of presentation was 47 years with an age range of 15 months to 71 years. Hoarseness (92.3 per cent) was the commonest symptom. The laryngoscopic appearances often simulated malignancy. Most patients (69.2 per cent) outnumbered ulcerative ones (38.5 per cent). Laryngeal oedema was infrequent (7.7 per cent). Diagnosis was based on a laryngeal biopsy in 18 patients and on evidence of associated pulmonary tuberculosis and response to anti-tuberculous therapy in eight. Chest X-rays showed apical cavitation and infiltration as the commonest findings. Three patients had miliary tuberculosis and one had no pulmonary lesion. Diabetes mellitus was present in seven (26.9 per cent) patients. Four illustrative cases are described. The problems in diagnosis and management of laryngeal tuberculosis are discussed.
A rare case of laryngeal tuberculosis in a 15-month-old Indian child is described. The unusual mode of presentation with stridor, suspicious radiological signs and papillomatus nature of the laryngeal lesion are highlighted.
The authors describe an unusual case of a primary chondroid chordoma arising from the base of petrous temporal bone. The patient, a young male, presented with a left sided jugular foramen syndrome. The CT findings of a tumour arising from the base of the left petrous temporal bone were confirmed at infratemporal exploration. The clinical and histopathological and immunohistochemical differences between classical (typical) chordoma and its chondroid variant are highlighted. The rarity of primary chordomas at this site is stressed.