Open surgical approach to management of rhino-orbito-cerebral mucormycosis

<p class="abstract"><strong>Background: </strong>Since December 2019, when novel corona virus (COVID 19) was reported, it has spread widely to cause a pandemic. Rhino-orbito-cerebral Mucormycosis (ROCM), an opportunistic fungal infection caused by the order Mucorales and class Zygomycetes has led to an epidemic in our country.</p><p class="abstract"><strong>Methods: </strong>This prospective cross sectional study was conducted at a 1200 bed tertiary care teaching hospital in Mysore. All patients of ROCM who presented to us for treatment were selected for the study after informed consent. Only those patients who were operated via open approach were included.</p><p class="abstract"><strong>Results:</strong> Median age of the patients was 50 years (SD±10). 49 were male patients (67.1%). Diabetes mellitus was the most common underlying co-morbidity seen in 71 patients (97.3%). Facial pain (100%) and facial swelling (90.4%) were the most common presenting complaint. KOH positivity from nasal swab for Mucormycosis was positive in only 37 patients (50.7%). Traditional inaccessible areas to endoscope like the premaxilla, lateral orbit cavity, infra temporal fossa and hard palate were tackled by the open surgical approach route. Advantages of open surgical approach being the access to areas which are traditionally difficult to approach via the endoscope, aggressive debridement is possible which might be challenging endoscopically. Complications like wound dehiscence, oro-antral fistula, osteomyelitis and abscess were noted in our study.</p><p class="abstract"><strong>Conclusions: </strong>Open surgical approach offers a very viable, affordable and a very effective means for aggressive surgical debridement of infection and reduce mortality associated with ROCM.</p><p> </p>

Vascular anatomy of temporal fossa

Τα ενέσιμα υαλουρονικού οξέος εφαρμόζονται για τη διόρθωση παραμορφώσεων του κροταφικού βόθρου που σχετίζονται με την ηλικία, παρέχοντας αύξηση μαλακών ιστών καθώς και υποστήριξη αυτών (ιστών). Αν και γενικά θεωρούνται ασφαλή, σημαντικές ανεπιθύμητες ενέργειες (ΑΕ) έχουν συσχετιστεί με χρήση αυτών. Η ενδελεχής γνώση της ανατομίας της περιοχής, καθώς και η αξιολόγηση των κινδύνων και τα οφέλη που σχετίζονται με τις διαφορετικές τεχνικές έγχυσης, είναι θεμελιώδεις για τη διασφάλιση βέλτιστων αποτελεσμάτων και την αποφυγή των ΑΕ. Ειδικότερα, η αγγείωση της κροταφικής περιοχής απαιτεί ιδιαίτερη προσοχή καθώς μπορεί να σχετίζεται με σοβαρές ΑΕ, όπως η αρτηριακή απόφραξη, ισχαιμία και εμβολή. Στα πλαίσια αυτά, διερευνήσαμε την ανατομία του κροταφικού βόθρου και τον τρόπο με τον οποίο σχετίζεται με τις αγγειακές AE ύστερα από ενέσιμα υαλουρονικού οξέος. Επιπλέον, εξαιτίας της έλλειψης δεδομένων στον τομέα της αισθητικής καθώς και των επιπτώσεων στις βαθιές κροταφικές αρτηρίες (deep temporal arteries), διερευνήσαμε και αξιολογήσαμε την ανατομία της περιοχής και την επίδραση αυτών των ενέσιμων θεραπειών επί των αγγείων.

Clipping of Multiple Cerebral Aneurysms Through Cranioorbital Zygomatic Approach: 2-Dimensional Operative Video

Ruptured cerebral aneurysm is a grave disease, with a high morbidity and mortality, mandating securing the aneurysm to eliminate fatal rebleeding.1 Multiple aneurysms are frequent and may occur in approximately 20% of the cases with female prominence.2 The risk of subarachnoid hemorrhage in unruptured aneurysms is higher in patients who had prior ruptured aneurysms.3 Hence, there is an indication of treating all concomitant aneurysms when one is ruptured. We present the case of clipping of 3 aneurysms via a cranioobritozygomatic (COZ) approach including a middle cerebral artery, anterior choroidal artery, and superior cerebellar artery in a patient presenting with subarachnoid hemorrhage and multiple aneurysms with suboptimal morphology for endovascular coiling. We highlight the advantages of the COZ in the clipping of complex posterior circulation aneurysms and the advantage of mobilization of neural structures to gain wider exposure.4-6 The temporal fossa space provided by zygomatic osteotomy allows the outward mobilization of the temporal lobe after freeing it by splitting the Sylvian fissure. The falciform ligament is opened overlying the optic nerve, allowing for safe dissection within the opticocarotid window. The oculomotor nerve is detethered from the dura surrounding its entry into the cavernous sinus. These maneuvers allow for mobilization of the critical neurovascular structures, which widens the operative corridor without undue traction or retraction. The COZ with clinoidectomy shortens and widens the operative field, allows for enhanced maneuverability, improved visualization, and exposure of the clinoidal carotid, and facilitates the release and mobilization of the optic and third nerve. The patient consented to surgery. Image at 1:40 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998.

Atypical Intratemporal Meningioma Masquerading as Otitis Media—Clinical and Radiological Diagnostic Dilemma

Meningiomas are the most common intracranial extra-axial neoplasms with mostly straightforward radiological diagnosis; however, they can have unusual clinical and imaging manifestations posing diagnostic dilemma for radiologists and clinicians. The objective of this case report is to highlight the infrequent and misleading presentations of meningiomas to make an accurate diagnosis. A 65-year-old male patient presented with complaints of left recurrent otitis media and facial nerve palsy for past 6 months. On imaging, an aggressive predominantly cystic intracranial neoplasm was found in the left temporal fossa extending into the middle and external ear. Histopathological examination of the excised tumor revealed WHO grade I meningothelial meningioma. Meningiomas can show atypical imaging features such as large meningeal cysts, heterogenous or ring enhancement and aggressive features such as bone erosion. They can invade the middle ear and should be thought of while dealing with nonresponsive cases of otitis media.

Morphometric evaluation of features of remodeling of chondrocites of joint surfaces of temporomandibular joint of experimental animals in hyperglycemia

Aim: to study morphometrically the peculiarities of remodeling of chondrocytes of the articular surfaces of the temporomandibular joint in hyperglycemia.Materials and methods: Quantitative morphological methods were used to study diameters of chondrocytes and their nuclei, nuclear-cytoplasmic relationship in these cells, relative volume of damaged chondrocytes, intercellular-chondrocytic relationship in mature chondrocytes of the articular surfaces of the temporomandibular joint of 45 laboratory mature white male rats with simulated diabetes.Results: A comprehensive analysis of the morphometric parameters presented in the article showed that they did not differ in the articular surfaces of the temporal fossa and mandibular head of the intact temporomandibular joint. The expressed structural changes of chondrocytes were revealed at a monthly and a two-month diabetic arthropathy of this joint.Conclusions: Proceeded studies and obtained results suggest that prolonged hyperglycemia leads to diabetic arthropathy of the TMJ, which is characterized by atrophy of chondrocytes, violation of nuclear-cytoplasmic relationships, an increase in the relative volume of damaged chondrocytes and volume of intercellular substance. The detected changes in quantitative morphological parameters depended on the duration of hyperglycemia and dominated in the cartilaginous tissue of the articular surface of the mandibular head.

Parotid Myoepithelial Carcinoma in a Pediatric Patient with Multiple Recurrences: Case Report

Myoepithelial carcinoma of the salivary glands is a rare entity, with scarce amount of case reports in the literature. Due to its infrequency, its diagnosis is usually difficult and uncertain. Although there are reports of locoregional recurrences and distant metastases, its low incidence and varied biological behavior limits the clinical evidence that can be used to predict the prognosis and determine the course of treatment. We present a 23-year-old female patient without past medical history with an initial 1-year history of volume increase in the right parotid region of tumor aspect and painful on palpation. As a malignancy was suspected, a total parotidectomy was performed, reporting in the deep lobe a parotid myoepithelial carcinoma with vascular and neural invasion, negative borders, and 3–9 negative regional nodes. During her 16-year clinical evolution, she presented approximately every 2 years and a total of 9 locoregional recurrences and hepatic metastases, including cervical lymphoid nodules, temporal bone, frontal bone, and temporal fossa. Those recurrences have been treated with coordinated efforts between repeated external radiotherapy, chemotherapy, and multiple surgical resections. Myoepithelial tumors represent only 1.0–1.5% of all salivary gland tumors. The literature reports suggest a high incidence of locoregional recurrences and distant metastases in de novo myoepithelial carcinomas. Due to its rarity, treatment continues to be based on the experience of medical staff.

Bamboo in the brain: Impalement injury over orbito-cranial region via superior orbital fissure

Intracranial wooden foreign bodies due to transorbital penetrating injury sparing orbital globe are relatively rare with no reported cases till date. A multidisciplinary approach with multiple imaging modalities is needed for preoperative surgical planning. In this case report, we report a case of 3-year-old male who presented to our emergency department with history of fall from 5 feet with no vision over right eye. ~2cm cut injury with sutures in situ was present over nasal ridge with pus discharge. CT scan head showed foreign body over temporal region. Right fronto-temporo-orbito-zygomatic craniotomy with removal of foreign body was done. Deep seated abscess seen over temporal fossa was evacuated and post-operatively intravenous antibiotics was continued. Contrast enhanced CT repeated on 15th post-operative day showed no remaining abscess or foreign body. The patient was discharged on oral antibiotics. The wound healed completely with no improvement of vision in 1-week follow-up. Keywords: brain abscess, orbito-cranial penetrating injury, wooden foreign body

Innovative Surgical Treatment of Cerebral palsy

Cerebral palsy means partial brain paralysis, like facial palsy where facial nerve is paralyzed. It is mainly due to birth induced asphyxia others a lot of causes also present. Convulsion is most common symptoms of cerebral palsy. This convulsion leads to further hypoxia which leads to further brain damage. Indirectly it is permanent and progressive disorder. Ultimately patient is unable to walk, communicate and perform normal life. Birth asphyxia leads to hyperostosis of skull bone. Premature closure of sutures specially fontanelle. Early closure of sutures of skull and fontanelle. At the same time temporal fossa is small and commonly temporal bone thickened excessively as a sequalae total intracranial volume decreased and which restrict to expansion of brain uniformly. As the age advances simultaneously brain also increase at its maximum level up to 5 years but rigid skull doesn’t allow the expansion of brain due to early closure of suture .and excessive growth of bones even in skull base. Temporal bone also exceptionally thickened. Normal as usual treatment failed to cure cerebral palsy patients. This new cranial vault reorganization or reconstruction by Bilateral cranioplasty and duraplasty giving surprising result of these cerebral palsy patients. This case hase been operated in Khwaja Yunus Ali Medical College and Hospital, Enayethpur, Sirajganj, Bangladesh. Patient’s appearance become quite normal just after operation. KYAMC Journal.2021;12(1): 56-59

A stem delphinidan from the Caribbean region of Venezuela

The dense Miocene record of cetaceans is known from localities along the coasts of all continents, mostly in the northern Atlantic or the eastern Pacific regions, but Antarctica. Fossils from the Caribbean region are few and include of a couple of findings from Panama and Venezuela. Here, we report a partly complete skull from the Caujarao Formation (middle Miocene), Falcon State, Caribbean region of Venezuela. Our phylogenetic analyses indicate that the Caujarao specimen is a ‘stem delphinidan’, a group that includes several taxa of early diverging odontocetes whose phylogenetic affinities remain a matter of debate. The fossil record has shown that this group of stem delphinidans was taxonomically diverse, but displayed a somewhat homogeneous cranial patterning, with most of the variations being found within the mandible or tympanoperiotic characters. As other stem delphinidans the Caujarao odontocete displays an enlarged temporal fossa and a fairly symmetrical cranium. Because the skull is missing several key diagnostic characters due to the preservation state of the specimen, a more precise taxonomic identification is not possible. Despite this, the finding of this specimen highlights the importance of the fossil record from the Neogene of Venezuela, and the importance of the area to understand cetacean evolution in the proto-Caribbean.