The rising burden of invasive fungal infections in COVID-19, can structured CT thorax change the game

Background The occurrence of invasive fungal infections in COVID-19 patients is on surge in countries like India. Several reports related to rhino-nasal-sinus mucormycosis in COVID patients have been published in recent times; however, very less has been reported about invasive pulmonary fungal infections caused mainly by mucor, aspergillus or invasive candida species. We aimed to present 6 sputum culture proved cases of invasive pulmonary fungal infection (four mucormycosis and two invasive candidiasis) in COVID patients, the clues for the diagnosis of fungal invasion as well as difficulties in diagnosing it due to superimposed COVID imaging features. Case presentation The HRCT imaging features of the all 6 patients showed signs of fungal invasion in the form of cavities formation in the pre-existing reverse halo lesions or development of new irregular margined soft tissue attenuating growth within the pre-existing or in newly formed cavities. Five out of six patients were diabetics. Cavities in cases 1, 2, 3 and 4 of mucormycosis were aggressive and relatively larger and showed relatively faster progression into cavities in comparison with cases 5 and 6 of invasive candidiasis. Conclusion In poorly managed diabetics or with other immunosuppressed conditions, invasive fungal infection (mucormycosis, invasive aspergillosis and invasive candidiasis) should be considered in the differential diagnosis of cavitary lung lesions.

Endoscopic findings of dental implant found in the infundibulum showing the mucociliary clearance of the maxillary sinus

Significance statement: A 53-year-old man with left facial pain was referred to our hospital. Nasal endoscopy revealed a purulent discharge at the left middle meatus and bulging of the uncinate process. Computed tomography demonstrated that the dental implant was blocking the left maxillary ostium. Functional endoscopic sinus surgery was performed under general anesthesia. After removal of the uncinate process, a yellowish purulent discharge in the left maxillary sinus discharged from the maxillary sinus. The presence of the dental implant in the infundibulum shows the direction of mucociliary clearance from the nasal sinus. This case indicates how our sinus clears a foreign body, and the direction in which the foreign body is removed.

Deep nasal sinus cavity microbiota dysbiosis in Parkinson’s disease

Olfactory dysfunction is a pre-motor symptom of Parkinson’s disease (PD) that appears years prior to diagnosis and can affect quality of life in PD. Changes in microbiota community in deep nasal cavity near the olfactory bulb may trigger the olfactory bulb-mediated neuroinflammatory cascade and eventual dopamine loss in PD. To determine if the deep nasal cavity microbiota of PD is significantly altered in comparison to healthy controls, we characterized the microbiota of the deep nasal cavity using 16S rRNA gene amplicon sequencing in PD subjects and compared it to that of spousal and non-spousal healthy controls. Correlations between microbial taxa and PD symptom severity were also explored. Olfactory microbial communities of PD individuals were more similar to those of their spousal controls than to non-household controls. In direct comparison of PD and spousal controls and of PD and non-spousal controls, significantly differently abundant taxa were identified, and this included increased relative abundance of putative opportunistic-pathobiont species such as Moraxella catarrhalis. M. catarrhalis was also significantly correlated with more severe motor scores in PD subjects. This proof-of-concept study provides evidence that potential pathobionts are detected in the olfactory bulb and that a subset of changes in the PD microbiota community could be a consequence of unique environmental factors associated with PD living. We hypothesize that an altered deep nasal microbiota, characterized by a putative pro-inflammatory microbial community, could trigger neuroinflammation in PD.

Current Biomarkers of Apoptosis Process in Chronically Inflamed Nasal Sinus Epithelium: Representatives of BAX, Bcl-2 and miRNA Group

In chronic upper respiratory tract diseases, increased cell proliferative activity is observed, which is coordinated by Bcl-2 proteins as well as by small non-coding RNAs.The aim of this study was to determine the expression of critical apoptosis markers at the mRNA and miRNA level in patients with chronic rhinosinusitis with nasal polyps (CSRwNP).The study group consisted of 10 patients with CSRwNP and 10 healthy controls. TUNEL staining was performed to detect in situ apoptosis in the maxillary sinus mucosa. The levels of selected mRNA transcripts associated with cell survival and apoptosis: BAX, p53, p21, CASP3, CASP9, c-MYC, CCND1, BRIC5 and APAF1 and miRNAs: miR-17-5p, miR-145-5p, miR-146a-5p and miR-203a-3p were determined by RT-qPCR. CSRwNP patients showed increased apoptosis determined by TUNEL assay accompanied by increased expression of BAX, P21, P53, CASP3, CASP9, c-MYC, APAF-1 transcripts and decreased mRNA levels of BCL-2 and BIRC5. There were increased expression levels of miR-203a-3p and decreased expression levels of miR-17-5p and miR-145-5p. These findings appear to be characteristic features of apoptosis in CRSwNP. The proapoptotic effect of miR-203a-3p may be crucial for future treatment strategies for CRSwNP.

Sinus Augmentation—Expect the Unexpected: Diagnostic Anatomical Study

“Big-nose variant” is an anatomical phenomenon defined as the pneumatization of inferior third of the nasal cavity within the alveolar ridge while simultaneously displacing the maxillary sinus laterally. The purpose of the present study was to assess the prevalence of the big-nose variant phenomenon and suggest a morphology classification system. Diagnostic anatomical evaluation was performed in a tertiary medical center on 321 randomly selected maxillary cone beam computerized tomography scans of patients who presented at an oral and maxillofacial department. Two anatomical categories were defined for anatomical identification: classes for horizontal mesiodistal distribution, and divisions for vertical distribution. Class 2, defined as location of the nasal/sinus border between the distal edge of the canine up to the distal edge of second premolar, was found to be the most prevalent (64.6%). Class 3, defined as location of the nasal/sinus border distal to mesial edge of the first molar, was found in 17.9% of cases. Regarding the divisions category, in 96% and 58.2% of teeth examined, nasal cavity alone was found to be superior to the canine and first premolar, respectively, defined as Division A. In 46.9% and 85.6% of teeth examined, maxillary sinus alone was located above the second premolar and first molar, respectively, defined as Division C. Identifying Class 3 on the paraxial reconstruction is the first step in identifying big-nose variant, with further assurance gained from each determining division. The use of the classes and divisions may enable better maxillary treatment planning, alert surgeons for the unexpected, and avoid complications.

Fibrous Histiocytoma of Anterior Ethmoidal Sinus: Case Report and Review of the Literature

Benign fibrous histiocytoma of the para nasal sinus is a rare tumor of this region which originates from mesenchymal cells. A 9-year-old girl presented with gradually enlarging mass above the medial canthus over 3 months. Orbital computerized tomography scan showed a round well-differentiated homogeneous mass in the anterior ethmoidal sinus. Histology and immunohistochemistry analysis after excision revealed proliferation of spindle-shaped fibroblasts in storiform pattern and histiocytes without mitosis and anaplasia. After 9 months from surgical excision, recurrence occurred which resulted in total excision again. This is the first reported case of benign fibrous histiocytoma involving the ethmoid sinus in Iranian people. Rare sinus tumor should be considered in the differential diagnosis of sinus tumors.

549 Use of 3D Printing Technology in Surgical Planning and Decision Making in ENT Skull Base Surgery- An Axial 3D First in Northern Ireland

39-year-old male seen at ENT clinic with inverted papilloma polyp of nasal sinus. CT showed multi-sinus mucosal thickening. The surgical options discussed were modified Lothrops endoscopic sinus surgery or an open approach of frontal sinuses with osteoplastic flap and septorhinoplasty. A model 3D skull was created by Axial 3D using stereolithography 3D printing technology with photopolymer resin. The skull was made in 1:1 scale with tolerance of 0.2mm. The tumour was printed in a contrasting colour, which allowed clear visualisation and appreciation of tumour boarders and relations to surrounding structures. The patient underwent FESS with modified Lothrops approach, achieving good clearance of polyp. The operation resulted in relief the patient’s symptoms. Discussion The use of a 3D model allowed for visualisation of tumour size and relation to surrounding anatomy, particularly the absence of dural involvement within the fontal sinus. It assisted in surgical planning. The use of the 3D skull was beneficial for patient as it allowed less invasive surgery and therefore shorter recovery time. It was also beneficial for the hospital organisation as it lowered resource requirements of theatre time, hospital bed days and staff resources. One limitation of the 3D printed skull was that the fine lamellae ethmoid air cells were not shown due to the manufacturing process. Conclusions The use of 3D printing is becoming increasingly popular as a surgical aid. We found the use of the 3D skull to be useful in individualised surgical planning for endoscopic sinus surgery.

A SURVEY ON RHINO - ORBITAL - CEREBRAL MUCORMYCOSIS PATIENTS - A POST COVID OCCURRENCE IN TERTIARY HOSPITAL

With increasing case reports of Rhino - Orbital - Cerebral Mucormycosis, a secondary infection to Post COVID condition, the present study aimed to find the occurrence of Mucormycosis across various age groups, its presence among vaccinated population, relation between hyperglycemia and mucormycosis, site of involvement of nasal/ sinus mucormycosis and the Culture based genus classification of fungal Mucormycosis. A total number of 250 patients diagnosed with either Confirmed/ Suspected Mucormycosis, a Post COVID infection were included in the study. For all the patients, their demographic data, comorbities, vaccination details, imaging findings and follow up information were obtained and statistically analyzed for the study. The results show that: a) A major of 36.4% of mucormycosis patients were found between the age range of 51 - 60 years. B) Vaccinated population is less vulnerable to COVID and its secondary infection - Mucormycosis. C) Site of involvement of Nasal/ Sinus Mucormycosis is found as a Combined Maxillary+Ethmoid+orbit involvement in 80.8% followed by Ehtmoidal involvement and palatal involvement. D) Presence of diabetes mellitus was present among 93.2% of the participants and E) The genus classification shows the occurrence of Rhizopus Arrhizus was the cause for mucormycosis found in many of the culture based fungal infection among the Post COVID patients involved in the study. The study concludes that patients treated for COVID in the age group of 30 years to 70 years are more vulnerable to acquire Mucormycosis. Glycemic control among the COVID treatment patients will grossly prevent the occurrence of Mucormycosis infection.

Sodium Toxicity in the Nutritional Epidemiology and Nutritional Immunology of COVID-19

Dietary factors in the etiology of COVID-19 are understudied. High dietary sodium intake leading to sodium toxicity is associated with comorbid conditions of COVID-19 such as hypertension, kidney disease, stroke, pneumonia, obesity, diabetes, hepatic disease, cardiac arrhythmias, thrombosis, migraine, tinnitus, Bell’s palsy, multiple sclerosis, systemic sclerosis, and polycystic ovary syndrome. This article synthesizes evidence from epidemiology, pathophysiology, immunology, and virology literature linking sodium toxicological mechanisms to COVID-19 and SARS-CoV-2 infection. Sodium toxicity is a modifiable disease determinant that impairs the mucociliary clearance of virion aggregates in nasal sinuses of the mucosal immune system, which may lead to SARS-CoV-2 infection and viral sepsis. In addition, sodium toxicity causes pulmonary edema associated with severe acute respiratory syndrome, as well as inflammatory immune responses and other symptoms of COVID-19 such as fever and nasal sinus congestion. Consequently, sodium toxicity potentially mediates the association of COVID-19 pathophysiology with SARS-CoV-2 infection. Sodium dietary intake also increases in the winter, when sodium losses through sweating are reduced, correlating with influenza-like illness outbreaks. Increased SARS-CoV-2 infections in lower socioeconomic classes and among people in government institutions are linked to the consumption of foods highly processed with sodium. Interventions to reduce COVID-19 morbidity and mortality through reduced-sodium diets should be explored further.

Frequency of Anatomical Variants of Paranasal Sinuses (PNS) on Computed Tomography (CT)

Background: The para nasal sinuses be collection of air filled spaces adjoining the nasal cavity. Para nasal sinuses build up as of the primitive choana at 25–28 weeks of gestation. Three projections ascend from the lateral wall of the nose and work as the commencement of the growth of the para nasal sinuses. The Frequency of Anatomical Variants of Para nasal Sinuses (PNS) may be illustrated on Computed Tomography (CT) by using double slice CT machine. Aim: To reveal the anatomy of the para nasal sinuses as shown on the CT along with point out the variants lead to chronic sinusitis and escort obstacles in sino nasal operations. Methodology: This study was conducted in Ibnae-e Sieena Hospital and MMDC Multan during September 2019 to December 2019. In 50 patients without para nasal sinus diseases symptoms, head computed tomography studies were carried out after having consent from them and IRB. Para nasal sinuses coronal sections were taken. The CT studies were performed by using Dual Source multi slice CT Scanner. Results: 50 participants included in the study, 25 men with 25 women. Out of them, 22 having anatomical variants were noticed. Most common anatomical variants found were pneumatisation of center nasal turbinates (30%) then agger nasi cells 25%, Haller’s cells 20%, along with septal deviation 13% and sphenoid sinus septation (12%). Conclusion: This study shows that nasal cavity and para nasal sinuses anatomical variations are common. For the radiologic analysis of the para nasal sinuses, as of diagnosis of the pre and post -surgical evaluation and sino-nasal lesions, CT is the gold standard procedure. It can outline and explain the anatomical variants in para nasal sinuses. CT not only detect the lesion to vital constitutions which lined the para nasal sinuses but also repeated lesions that extra mural cells. CT of the para nasal sinuses has vital importance and should be passably analyze before FESS. Keywords: Para nasal sinuses, Computed tomography, Nasal turbinate, Ostiomeatal complex