Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1

Purpose

COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management.

Methods

This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021.

Results

Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05).

Conclusion

: Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.

Musculoskeletal Changes as a Sequel to Advancement Genioplasty: A Long-Term Cephalometric Prospective Study

Aims

The aim of this study was to evaluate cephalometrically the stability of hard tissues and soft tissue changes of advancement genioplasty 2 years after surgery.

Methods

A prospective study was conducted which comprised of 25 patients, who underwent advancement genioplasty alone with no other orthognathic surgical procedures. Immediate pre-operative, 6 months postoperative, and 2 years postoperative lateral cephalograms were compiled and assessed.

Results

The mean surgical advancement planned was around 8 mm. Six months post-surgery, the relapse rate was 15% of the surgical advancement which was considerably reduced in the following 18 months to 7%. The ratio of soft tissue to bony advancement at pogonion was 0.9:1. There are significant alterations in the soft tissue profile in terms of decrease in the soft tissue thickness, facial convexity angle, deepened mentolabial sulcus and minimal increase in the lower lip height.

Conclusion

Advancement genioplasty was considered as a relatively stable procedure, if adequate muscular pedicle and internal rigid fixation were maintained. The present study was of 2 years, and we can expect further changes in the hard and soft tissues, which are clinically irrelevant.

Ropivacaine: a new local anaesthetic agent in maxillofacial surgery

We have compared the anaesthetic efficacy, duration of action, pain, pulpal anaesthesia, and cardiovascular effects of 0.5% ropivacaine or 2% lignocaine hydrochloride in bilateral symmetrical impacted third molars. In a randomised single-blind trial we studied 78 healthy patients who required bilateral extraction of identical impacted lower third molars. A test dose was given to all patients with subdermal infiltration of 0.5% ropivacaine 0.5 ml. A classic inferior alveolar and long buccal nerve block was created using 0.5% ropivacaine 2 ml on one side and 2% lignocaine hydrochloride 2 ml with adrenaline on the other. The time to onset and duration of action were noted. Pain, numbness of the lip and tip of the tongue, and haemodynamic changes were monitored throughout the procedure. The teeth were extracted two weeks apart. The onset of anaesthesia ranged between 2 and 3 min after the injection and lasted for more than 5h. Ropivacaine alone did not cause appreciable changes in the cardiovascular variables, but lignocaine with adrenaline caused a transient increase in arterial pressure and heart rate 2 min after injection. We conclude the 0.5% ropivacaine alone does not affect the cardiovascular system and has more beneficial effects than 2% lignocaine hydrochloride with adrenaline. These findings may be useful for oral and maxillofacial surgeons who are looking for a local anaesthetic with minimal cardiovascular risk and without a vasoconstrictor to provide regional anaesthesia for long procedures.