Publications by authors named "Alok Thakar"

179 Publications

Hearing Rehabilitation of Patients with Chronic Otitis Media: A Discussion of Current State of Knowledge and Research Priorities.

J Int Adv Otol 2022 Jul;18(4):365-370

Department of Otorhinolaryngology, Donders Centre for Neurosciences, Radboud University Medical Center, Nijmegen, Netherlands; Department of Otorhinolaryngology/Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Research School of Behavioral and Cognitive Neurosciences, Graduate School of Medical Sciences, University of Groningen, Groningen, Netherlands.

Although chronic otitis media is a major cause of conductive and mixed hearing loss, auditory rehabilitation is currently not optimal for this patient group. Planning for hearing rehabilitation must accompany strategies for infection control when surgically managing patients with chronic otitis media. Several barriers prevent adequate hearing restoration in such a heterogeneous patient population. A lack of standardized reporting of surgical interventions, hearing, and quality of life outcomes impedes meta-analyses of existing data and the generation of high- quality evidence, including cost-effectiveness data, through prospective studies. This, in turn, prevents the ability of clinicians to stratify patients based on prognostic indicators, which could guide the decision-making pathway. Strategies to improve reporting standards and methods have the potential to classify patients with chronic otitis media preoperatively, which could guide decision-making for hearing restoration with ossicu- loplasty versus prosthetic hearing devices. Appropriately selected clinical guidelines would not only foster directed research but could enhance patient-centered and evidence-based decision-making regarding hearing rehabilitation in the surgical planning process.
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http://dx.doi.org/10.5152/iao.2022.21428DOI Listing
July 2022

Authors' response.

Indian J Med Res 2022 Jan;155(1):216

Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/0971-5916.351022DOI Listing
January 2022

Airway management, procedural data, and in-hospital mortality records of patients undergoing surgery for mucormycosis associated with coronavirus disease (COVID-19).

J Mycol Med 2022 Jul 2;32(4):101307. Epub 2022 Jul 2.

Department of Onco-anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Purpose: Although unexpected airway difficulties are reported in patients with mucormycosis, the literature on airway management in patients with mucormycosis associated with Coronavirus disease is sparse.

Methods: In this retrospective case record review of 57 patients who underwent surgery for mucormycosis associated with coronavirus disease, we aimed to evaluate the demographics, airway management, procedural data, and in-hospital mortality records.

Results: Forty-one (71.9%) patients had a diagnosis of sino-nasal mucormycosis, fourteen (24.6%) patients had a diagnosis of rhino-orbital mucormycosis, and 2 (3.5%) patients had a diagnosis of palatal mucormycosis. A total of 44 (77.2%) patients had co-morbidities. The most common co-morbidities were diabetes mellitus in 42 (73.6%) patients, followed by hypertension in 21 (36.8%) patients, and acute kidney injury in 14 (28.1%) patients. We used the intubation difficulty scale score to assess intubating conditions. Intubation was easy to slightly difficult in 53 (92.9%) patients. In our study, mortality occurred in 7 (12.3%) patients. The median (range) mortality time was 60 (27-74) days. The median (range) time to hospital discharge was 53.5 (10-85) days. The median [interquartile range] age of discharged versus expired patients was 47.5 [41,57.5] versus 64 [47,70] years (P = 0.04), and median (interquartile range) D-dimer levels in discharged versus expired patients was 364 [213, 638] versus 2448 [408,3301] ng/mL (P = 0.03).

Conclusion: In patients undergoing surgery for mucormycosis associated with the coronavirus disease, airway management was easy to slightly difficult in most patients. Perioperative complications can be minimized by taking timely and precautionary measures.
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http://dx.doi.org/10.1016/j.mycmed.2022.101307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9250164PMC
July 2022

Metastatic Malignant Phosphaturic Mesenchymal Tumor of Mandibular Alveolus: a Rare Case Report and Review of Literature.

Indian J Surg Oncol 2022 Jun 22;13(2):305-311. Epub 2021 Sep 22.

Department of Otolaryngology, Head and Neck Surgery, ENT Office 4057, 4th floor Academic Block AIIMS, New Delhi, 110029 India.

Malignant phosphaturic mesenchymal tumors (PMT) of the head and neck region are extremely rare, which cause paraneoplastic syndrome characterized by hypophosphatemia and osteomalacia. We report a 48-year-old gentleman who had persistent knee and calf pain associated with weakness in lower limbs on presentation. He had hypophosphatemia and elevated FGF-23 and  Ga-DOTANOC PET scan showed soft tissue density mass with increased peripheral radiotracer uptake in the left mandibular alveolus and adjoining floor of the mouth, revealing the primary tumor. It also showed a non-avid, histological inconclusive nodule of 17 × 12 mm in size in the lower lobe of the right lung. The patient was treated with composite resection and bilateral level I-III neck dissection with microvascular free fibula osteocutaneous flap mandibular reconstruction. Histopathological examination showed malignant PMT with positive soft tissue margins and bilateral metastatic cervical lymphadenopathy. The patient received adjuvant radiation therapy and sequential post therapy scans showed no evidence of locoregional disease, however showed progressive functional pulmonary metastatic disease which did not respond to chemotherapy. We also made a brief review of literature of head and neck malignant PMT focusing on presentation, primary and adjuvant treatment, and response to treatment.
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http://dx.doi.org/10.1007/s13193-021-01449-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9240173PMC
June 2022

Use of free jejunal flap as a salvage procedure in the management of high corrosive esophageal re-strictures: an institutional experience and review of literature.

Langenbecks Arch Surg 2022 Jun 27. Epub 2022 Jun 27.

Department of Otorhinolaryngology, All India Institute of Medical Sciences, New Delhi, India.

Background: High pharyngo-esophageal strictures following corrosive ingestion continue to pose a challenge to the surgeon, particularly in the developing world. With the advancements and increased experience with microsurgical techniques, free jejunal flaps offer a viable reconstruction option in patients with high corrosive strictures with previous failed reconstruction. We review our experience with free jejunal flap in three cases with high pharyngo-esophageal stricture following corrosive ingestion, with previous failed reconstruction.

Materials And Methods: A total of three patients underwent salvage free jejunal flap after failed reconstruction for high pharyngo-esophageal strictures following corrosive acid ingestion. All the three patients developed anastomotic leak and subsequent stricture, two following a pharyngo-gastric anastomosis and one following a pharyngo-colic anastomosis. The strictured segment was bridged using a free jejunal graft with microvascular anastomosis to the lingual artery and common facial vein. All patients were followed-up at regular intervals.

Results And Conclusions: The strictured pharyngeal anastomotic segment was successfully reconstructed with free jejunal flap in all the three patients. Patients were able to take food orally and maintain nutrition without the need of jejunostomy feeding. On long-term follow-up (median: 5 years), there was no recurrence of dysphagia and all the patients had good health-related quality of life.
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http://dx.doi.org/10.1007/s00423-022-02595-5DOI Listing
June 2022

Mucormycosis in COVID-19 Patients: A Case-Control Study.

Microorganisms 2022 Jun 13;10(6). Epub 2022 Jun 13.

Department of Otolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi 110029, India.

(1) Background: During the second wave of COVID-19, India faced a rapid and sudden surge of not only COVID19-delta variant cases but also mucormycosis, making the infection even more fatal. We conducted a study to determine factors associated with the occurrence of mucormycosis in patients with COVID-19. (2) Methods: This case-control study comprised 121 patients; 61 cases (mucormycosis with COVID-19) and 60 controls. Patients were included from April 10, 2021 onwards. Follow-up was conducted after about 90 days and health status was recorded based on the modified Rankin Scale (mRS). (3) Results: Mucormycosis with COVID-19 cases had a median (IQR) age of 49 (43-59) years with 65.6% males and were older (95% CI 1.015-1.075; = 0.002) than in the control group with median (IQR) 38 (29-55.5) years and 66.6% males. Baseline raised serum creatinine (OR = 4.963; 95% CI 1.456-16.911; = 0.010) and D-dimer (OR = 1.000; 95% CI 1.000-1.001; = 0.028) were independently associated with the occurrence of mucormycosis in COVID-19 patients. Additionally, diabetes mellitus (OR = 26.919; 95% CI 1.666-434.892; = 0.020) was associated with poor outcomes and increased mortality in patients with mucormycosis with COVID-19 as per the multivariable analysis. A total of 30/61 mucormycosis patients had intracranial involvement. (4) Conclusions: The study observed elevated levels of baseline raised creatinine and D-dimer in mucormycosis pa-tients with COVID-19 as compared to the control group. However, future studies may be conducted to establish this cause-effect relationship.
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http://dx.doi.org/10.3390/microorganisms10061209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9229175PMC
June 2022

Healthcare consumption among subjects with otitis media undergoing middle ear surgery-analysis of cost drivers.

Eur Arch Otorhinolaryngol 2022 Jun 22. Epub 2022 Jun 22.

Department of Otorhinolaryngology, Donders Centre for Neurosciences, Radboud University Medical Center, Nijmegen, The Netherlands.

Purpose: To map healthcare utilized by subjects with chronic otitis media, with or without cholesteatoma and perform a cost analysis to determine key drivers of healthcare expenditure.

Methods: A registry study of 656 adult subjects with chronic otitis media that underwent a middle ear surgery between 2014 and 2018. Healthcare contacts related to all publicly funded specialist ENT care, audiological care and primary care for a disease of the ear and mastoid process were extracted. The data are extracted from the Swedish National Patient Registry on subjects that reside in western Sweden.

Results: Subjects made 13,782 healthcare contacts at a total cost 61.1 million SEK (6.0 million EUR) between 2014 and 2018. The mean cost per subject was 93,075 SEK (9071 EUR) and ranged between 3971 SEK (387 EUR) and 468,711 SEK (45,683 EUR) per individual. In the most expensive quartile of subjects, mean cost was 192,353 SEK (18,747 EUR) over the 5-year period. These subjects made 3227 ENT contacts (roughly four each year) and 60% of total costs were associated with in-patient ENT care.

Conclusion: Patients with chronic otitis media are associated with high ENT resource utilization that does not diminish after surgical intervention and the disease places a long-term burden on healthcare systems. Significant costs are attributed to revision surgeries, indicating that these patients could be managed more effectively. In many such cases, reoperation cannot be avoided, especially due to recurrence of cholesteatoma. However, in some patients, when the indication for subsequent surgery is only hearing improvement, alternative options, such as hearing aids or implants, should also be considered. This is especially true in difficult cases, where revision ossiculoplasty is likely.
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http://dx.doi.org/10.1007/s00405-022-07483-8DOI Listing
June 2022

Effects of RME on Hearing in UCLP Patients: A Pilot Study.

Cleft Palate Craniofac J 2022 Jun 8:10556656221104945. Epub 2022 Jun 8.

Department of Otorhinolaryngology and Head and Neck Surgery, 28730All India Institute of Medical Sciences, New Delhi, India.

Objective: To assess the changes in hearing after rapid maxillary expansion (RME) and at the end of 6 months retention period in complete unilateral cleft lip and palate (UCLP) patients using pure tone audiometry and tympanometry test.

Design: Prospective pilot study.

Setting: Tertiary health care teaching hospital in New Delhi.

Patients: This study was conducted on 6 UCLP patients in the age range of 6-14 years with normal ear anatomy. All 6 patients had undergone primary repair of cleft lip and palate and required no more than 5 mm expansion in the intermolar region.

Intervention: RME was done using a Hyrax expander with daily activation of one-quarter turn per day for a period of 15-20 days (0.25 mm per day).

Main Outcome Measure: Audiometry and tympanometry readings at the baseline as compared to the post expansion and at the end of 6 months retention period.

Results: There were no significant changes in the hearing levels on the audiometry test after RME on the cleft side (-value -0.51) and the noncleft side ear (-value -0.26). No significant changes were observed in the middle ear volume on the tympanometry test after RME on the cleft side (-value -0.09) and the noncleft side ear (-value -0.28).

Conclusion: There was no improvement or deterioration in the hearing levels after RME and at the end of 6 months retention period in UCLP patients as evaluated using pure tone audiometry and tympanometry test. Hence RME may be undertaken in UCLP patients safely in terms of hearing is concerned.
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http://dx.doi.org/10.1177/10556656221104945DOI Listing
June 2022

Estimation of Serum Levels of Heavy Metals in Patients with Chronic Invasive Fungal Rhinosinusitis Before the COVID-19 Era: A Pilot Study.

Turk Arch Otorhinolaryngol 2022 Mar 12;60(1):29-35. Epub 2022 May 12.

Department of Otorhinolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India.

Objective: Various metals play role in the survival and pathogenesis of the invasive fungal disease. The objectives of this study were to compare the levels of heavy metals in patients with chronic invasive fungal rhinosinusitis (CIFR) and healthy controls, and to analyze their role in disease outcome.

Methods: Twenty-three patients (15 with invasive mucormycosis and 8 with invasive aspergillosis, Group 1), and 14 healthy controls (Group 2) were recruited. Blood samples were collected from each group into ion-free tubes and analyzed for serum levels of Nickel (Ni), Copper (Cu), Zinc (Zn), Gallium (Ga), Arsenic (As), Selenium (Se), Rubidium (Rb), Strontium (Sr), Cadmium (Cd), and Lead (Pb). The final outcome of the patients during their hospital stay was categorized clinico-radiologically as improved or worsened, or death.

Results: The levels of all metals were higher in Group 1 except for As and Pb. However, the differences in Cu (p=0.0026), Ga (p=0.002), Cd (p=0.0027), and Pb (p=0.0075) levels were significant. Higher levels of Zn (p=0.009), Se (p=0.020), and Rb (p=0.016) were seen in the invasive aspergillosis subgroup. Although Zn (p=0.035), As (p=0.022), and Sr (p=0.002) levels were higher in patients with improved outcome, subgroup analysis showed no differences.

Conclusion: The levels of some heavy metals in CIFR significantly differ from those of the general population and also vary with the type of the disease and its outcome. These levels may not have a direct effect on the outcome of the patient, but they do play a role in the pathogenesis of the invading fungus.
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http://dx.doi.org/10.4274/tao.2022.2021-11-12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9103563PMC
March 2022

Metastases to the Parotid Gland: Study from a Tertiary Care Centre.

Head Neck Pathol 2022 May 16. Epub 2022 May 16.

Department of Radiation Oncology, BRA Institute Rotary Cancer Hospital and National Cancer Institute, All India Institute of Medical Sciences, New Delhi, 110029, India.

Background: Metastases account for 6-25% of parotid tumors, often presenting dilemmas in their diagnosis.

Methods: Parotid metastases diagnosed on histology/cytology were retrieved. MUC2, MUC5AC, androgen receptor immunohistochemistry was performed in select cases.

Results: Fifty-one samples were identified from 42 patients, including 14 aspirates, 7 biopsies and 30 parotidectomies. Previous history was available in 17 cases, 13 parotidectomies accompanied excision of the primary, and relevant clinical data was unavailable for 12 patients. Majority (81%) had head and neck primaries; eye and ocular adnexa were the commonest subsite (52.4%), and sebaceous carcinoma the commonest histology (33%). When history was unavailable, most metastases were initially diagnosed as poorly differentiated carcinoma/malignant tumor, or mucoepidermoid carcinoma on cytology.

Conclusions: Intraparotid metastases encompass a wide spectrum, often mimicking primary salivary gland neoplasms, particularly on limited samples. Metastases should be considered when histological/cytological features are unusual; detailed clinical information and ancillary techniques aid in arriving at an accurate diagnosis.
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http://dx.doi.org/10.1007/s12105-022-01458-1DOI Listing
May 2022

Objective Comparison of Benefits Derived From Contralateral Routing of Signal Hearing Aid and Bone Conduction Device in Noisy Surroundings in Patients With Single-Sided Deafness.

J Audiol Otol 2022 Apr 12. Epub 2022 Apr 12.

Department of Otorhinolaryngology & Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.

Background And Objectives: Single-sided deafness (SSD) leads to non-participation of the diseased ear in generating adequate auditory input, which results in poor speech discrimination in noisy surroundings. The present study objectively compared the audiological benefits rendered by contralateral routing of signal (CROS) hearing aid and bone conduction device (BCD) in patients with SSD >70 dB HL using the modified hearing in noise test (HINT).

Materials And Methods: Patients with SSD >70 dB HL in poor and clinically normal hearing in the better ear were enrolled. Patients aged <18 or >70 years, with a history of neurological insult or ear infection in the last 3 months, mental retardation, psychiatric or developmental disorders, and diabetes were excluded. Modified HINT was performed with the affected ear unaided, aided with CROS hearing aid, and with BCD, generating three groups. Noise signal was presented at a fixed intensity of 65 dB at the neutral position in the center and speech signal was presented to either ear sequentially. The test was repeated with the speech signal fixed at the neutral position and the noise signal presented to either ear.

Results: BCD led to a better signal-to-noise ratio (SNR) than CROS hearing aid in all situations except when noise was centralized and speech was presented to the affected ear.

Conclusions: A benefit was observed when auditory rehabilitation was used for the affected ear as demonstrated by better SNR scores. The results showed that BCD performed better than CROS hearing aid.
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http://dx.doi.org/10.7874/jao.2021.00682DOI Listing
April 2022

Experience on rhino-orbital mucormycosis from a tertiary care hospital in the first wave of COVID-19: An Indian perspective.

Med J Armed Forces India 2022 Apr 2. Epub 2022 Apr 2.

Professor, Oculoplastics, Tumor & Pediatric Ophthalmology Services, Dr R. P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India.

Background: To highlight the clinical presentations and management outcomes of rhino-orbital mucormycosis during first wave of COVID-19 pandemic in North India.

Methods: A retrospective observational study. 15 patients with mucormycosis (orbital disease) who presented during short span of 3 months (October-December 2020) in a tertiary-care referral institution were analysed.

Results: At presentation, 13 of 15 patients had uncontrolled diabetes. Four had history of COVID-19 infection. All patients had advanced orbital disease with sinusitis; cavernous sinus involvement was in nine and intracranial spread in three patients. Liposomal amphotericin-B was started and prompt orbital exenteration with sinus surgery was performed in 12 patients. All 12 patients survived with an average follow-up of 4.8 months.

Conclusion: In the present series, cases with orbital spread of mucormycosis were mostly found in non-COVID uncontrolled diabetics. Exenteration was done in 80% of cases with advanced orbital disease. Prevention and early detection of infection at the stage of sino-nasal involvement might help to prevent spread and/or halt the orbital disease.
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http://dx.doi.org/10.1016/j.mjafi.2022.01.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8975717PMC
April 2022

SATB2 Immunopositivity in Spindle Cell (Sarcomatoid) Squamous Cell Carcinoma: A Potential Pitfall in Diagnosis.

Appl Immunohistochem Mol Morphol 2022 03;30(3):184-189

Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India.

Spindle cell squamous cell carcinomas (SpSCC) are aggressive neoplasms constituting 1% of oral cavity tumors. A proportion of SpSCC do not stain with epithelial markers, and frequently express mesenchymal markers, viz. Vimentin, smooth muscle actin, muscle specific actin, S100 and desmin, confounding the diagnosis. Immunoexpression of SATB2, a transcription factor indicating osteoblastic lineage, has not been evaluated in SpSCC previously. We therefore performed SATB2 immunohistochemistry in 15 cases of SpSCCs and scored them with respect to intensity and percentage of tumor cells stained. SATB2 immunopositivity was identified in 9/15 (60%) SpSCCs, with varying intensity and distribution. Eight cases (53.3%) showed nonfocal staining of moderate to strong intensity, and 1 case (6.7%) showed focal weak staining. Of these, 3 cases (3/9; 33.33%) did not stain with epithelial/squamous markers. Thus, a subset of SpSCC demonstrate SATB2 immunopositivity. In oral tumors with bone involvement, SATB2 positivity may lead away from the diagnosis of SpSCC. Knowledge of this aberrant immunostaining is, therefore, extremely relevant to guard against misdiagnosis as osteosarcoma, particularly on biopsies which lack adjacent dysplastic epithelium, in cases which are monophasic spindle cell, and in those that do not show immunopositivity for epithelial/ squamous markers. Our results emphasize that an appropriate panel and not a single immunomarker is required to distinguish SpSCC from mesenchymal tumors including osteosarcoma.
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http://dx.doi.org/10.1097/PAI.0000000000000986DOI Listing
March 2022

In Reference to Functional Imaging in Juvenile Angiofibroma.

Laryngoscope 2022 06 1;132(6):E25. Epub 2022 Mar 1.

Department of Nuclear Medicine Teaching Block, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1002/lary.30088DOI Listing
June 2022

Prevalence of hearing loss in India.

Natl Med J India 2021 Jul-Aug;34(4):216-222

Department of Non-communicable Diseases, Indian Council of Medical Research, New Delhi, India.

Background Despite abundant literature, a clear and coherent understanding of hearing loss (HL) in India is limited by the wide disparity in studies. Methods We did a review of published peer-reviewed journal articles. Studies reporting the prevalence and degree of HL in India from 1980 to 2020 were included. Information was gathered on the population characteristics, methodology applied and the prevalence of hearing impairment. The data were analysed to identify trends and at-risk sections of population in various categories. Results Four hundred and forty studies were identified after a database search; 29 full-length articles were selected for final analysis. Using a 3-step screening protocol, hearing impairment (abnormal auditory brainstem response/auditory steady state response) in neonates ranged between 1.59 and 8.8 per 1000 births. Among 'at risk' neonates, it ranged from 7 to 49.18 per 1000 births. In children the prevalence of HL was 6.6% to 16.47%. Otitis media was the most common cause of HL in children. Community-based studies (all ages) reported prevalence of HL between 6% and 26.9% and prevalence of disabling HL between 4.5% and 18.3%. Rural areas and elderly showed a higher prevalence of hearing impairment. Conclusion Despite India's improving health indices, hearing disability remains persistently high. It is a major contributor to the loss of personal potential and a financial strain for the individual and the country. A large-scale multicentric study to identify the degree and type of HL, social awareness campaigns, widespread neonatal screening, strengthening treatment facilities and well-funded rehabilitation programmes can counter the rising prevalence of hearing impairment.
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http://dx.doi.org/10.25259/NMJI_66_21DOI Listing
March 2022

Spectrum of mycobacterial pathogens responsible for head and neck tuberculosis-like presentation.

Access Microbiol 2021 17;3(12):000304. Epub 2021 Dec 17.

Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India.

Tuberculosis (TB) of the head and neck can be contained in the lymph nodes, larynx, oropharynx, salivary glands, nose and paranasal sinuses, ear, skin and skull. Head and neck TB presentations are varied in nature and thus difficult to diagnose. The clinical features, radiological findings, microbiological diagnostic modalities, surgical and medical management and outcomes of nine cases of head and neck TB are discussed in detail here, together with a thorough review of the literature. Patients presented with atypical symptoms such as discharging sinus, ear lobule swelling, otitis media, vision loss and facial weakness, long refractory otorrhoea and granulation tissue in the ear canal. We diagnosed tubercular skull base osteomyelitis (one case) and laryngeal tuberculosis (two cases), mastoid tuberculosis (one case) and non-tubercular mycobacterial infection involving the temporal bone (two cases), sino-nasal region (one case), maxilla (one cases) and ear lobule (one case) over a period of 8 months. All patients were managed successfully with a combination of surgery and a well-planned treatment regimen for non-tuberculous mycobacteria (NTM) or anti-tubercular drugs for TB. All had successful outcomes except one patient with tubercular skull base osteomyelitis who expired before the initiation of anti-tubercular therapy (ATT). High clinical suspicion followed by thorough diagnostic work-up for both TB and NTM would enable early diagnosis and complete treatment.
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http://dx.doi.org/10.1099/acmi.0.000304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8749145PMC
December 2021

Risk factors for Coronavirus disease-associated mucormycosis.

J Infect 2022 Mar 30;84(3):383-390. Epub 2021 Dec 30.

Department of Medicine, AIIMS, Delhi, India.

Background: The epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is poorly elucidated. We aimed to identify risk factors that may explain the burden of cases and help develop preventive strategies.

Methods: We performed a case-control study comparing cases diagnosed with CAM and taking controls as recovered COVID 19 patients who did not develop mucormycosis. Information on comorbidities, glycemic control, and practices related to COVID-19 prevention and treatment was recorded. Multivariate regression analysis was used to identify independent predictors.

Results: A total of 352 patients (152 cases and 200 controls) diagnosed with COVID-19 during April-May 2021 were included. In the CAM group, symptoms of mucormycosis began a mean of 18.9 (SD 9.1) days after onset of COVID-19, and predominantly rhino-sinus and orbital involvement was present. All, but one, CAM cases had conventional risk factors of diabetes and steroid use. On multivariable regression, increased odds of CAM were associated with the presence of diabetes (adjusted OR 3.5, 95% CI 1.1-11), use of systemic steroids (aOR 7.7, 95% CI 2.4-24.7), prolonged use of cloth and surgical masks (vs. no mask, aOR 6.9, 95%CI 1.5-33.1), and repeated nasopharyngeal swab testing during the COVID-19 illness (aOR 1.6, 95% CI 1.2-2.2). Zinc therapy was found to be protective (aOR 0.05, 95%CI 0.01-0.19). Notably, the requirement of oxygen supplementation or hospitalization did not affect the risk of CAM.

Conclusion: Judicious use of steroids and stringent glycemic control are vital to preventing mucormycosis. Use of clean masks, preference for N95 masks if available, and minimizing swab testing after the diagnosis of COVID-19 may further reduce the incidence of CAM.
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http://dx.doi.org/10.1016/j.jinf.2021.12.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8717704PMC
March 2022

TransOral UltraSonic surgery (TOUSS) for oral cavity, oropharyngeal and supraglottic malignancy: A prospective study of feasibility, safety, margins, functional and survival outcomes.

Oral Oncol 2022 01 11;124:105643. Epub 2021 Dec 11.

Department of Radiotherapy, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Introduction/background: With the advent of TransOral Robotic Surgery (TORS) the ease of transoral procedures has been dramatically improved. TORS is already established for its feasibility, functional and oncological outcomes for selected lesions of oral cavity, oropharynx and laryngopharynx. This study reports on preliminary results with TransOral UltraSonic Surgery (TOUSS) for oncologic resections of oral cavity, oropharyngeal and supraglottic malignancies.

Materials And Methods: Eighteen patients with malignancies of oral cavity, oropharynx and supraglottis underwent TOUSS with simultaneous neck dissection and adjuvant therapy as indicated, from January 2018 to April 2019. Essential equipment included the FK-retractor (Gyrus Medical, Tuttilngen, Germany) for TransOral exposure, the Olympus ENDOEYE Flex 5 mm 2D/10 mm 3D deflecting tip video laparoscopes, and 35 cm long ultrasonic harmonic scalpel (Thunderbeat). Parameters evaluated include tumor staging, mouth opening, TOUSS setup time, TOUSS primary removal time, surgical margins, blood transfusions, tracheostomy, postoperative complications, enteral feeding and resumption of oral diet, duration of hospital stay, and survival outcomes.

Results: Eighteen patients underwent complete TransOral UltraSonic Surgery (TOUSS), with simultaneous unilateral or bilateral neck dissection. No procedure was abandoned intraoperatively due to difficulty in extirpation of the tumor. Margins were negative for ten patients (55.6%), close in five (27.8%), and positive in three patients (16.7%). Average TOUSS set-up time was 22.5 min (range, 10-30 min) and average TOUSS primary tumor removal time was 35.3 min (range, 15-60 min). Patients started tolerating oral feeds even in the second post op day (mean 6 days), and transitioning to complete oral feeds with removal of the nasogastric tube was achieved in all (mean, 16 days). The average hospital stay was 7.4 days (range 2-16 days). Secondary hemorrhage occurred in two cases and required an emergency tracheostomy and ligation of lingual artery. Minor cervicopharyngeal fistula occurred in four cases and settled in all with conservative non-surgical treatment. Overall survival at 3 years was 70.5%, and disease-specific survival was 94.4%.

Conclusion: TransOral UltraSonic Surgery (TOUSS) is a safe and sound alternative method of endoscopic surgical treatment of oral cavity, oropharynx and supraglottic neoplasms. Advantages of this technique include faster resection time, intraoperative assistance from Narrow Band Imaging, easy affordability compared to TORS, and excellent functional outcomes.
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http://dx.doi.org/10.1016/j.oraloncology.2021.105643DOI Listing
January 2022

Archetype of Olfactory and Gustatory Dysfunction in Breakthrough COVID-19 Illness.

Indian J Otolaryngol Head Neck Surg 2021 Nov 25:1-3. Epub 2021 Nov 25.

Department of Otolaryngology and Head Neck Surgery, AIIMS, New Delhi, 110029 India.

Vaccination against SARS CoV-2 has resulted in COVID-19 illness with reduced incidence and milder symptomatology. With the intent to analyze the olfactory and gustatory disturbances in breakthrough COVID-19 illness, we conducted a prospective observational study on a cohort of COVID-19 positive symptomatic otolaryngologist physicians. These doctors being well sensitized to the symptoms and signs of loss of smell and taste, reported even very mild and transient symptoms. This cohort of 25 physicians included 16 unvaccinated and 9 vaccinated otolaryngologists. The overall incidence of smell and taste disturbances reported in this cohort was 80% and 84% respectively. The incidence of olfactory dysfunction was 81% in the unvaccinated group and 78% in the vaccinated group. Similarly, the incidence of gustatory dysfunction was 81% in the unvaccinated group and 89% in the vaccinated group. However, the incidence of complete loss of smell was 54% in the unvaccinated group and 100% in the vaccinated group. Ageusia was noted in 15% of the unvaccinated physicians as compared to 25% of the vaccinated ones. The average duration of smell and taste loss were lesser in the physicians who were vaccinated with two doses than their unvaccinated counterparts. Larger studies are desirable to add further knowledge on the equal incidences and higher degree of loss of smell and taste observed in breakthrough COVID-19 illness as observed in our small prospective cohort study.
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http://dx.doi.org/10.1007/s12070-021-02998-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8613458PMC
November 2021

Initial and ongoing challenges with COVID-19-associated mucormycosis.

Indian J Ophthalmol 2021 12;69(12):3391-3393

Department of ENT and Head Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/ijo.IJO_2237_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8837338PMC
December 2021

Cell-free EBV DNA as a biomarker during clinical management of nasopharyngeal carcinoma in a nonendemic region.

J Med Virol 2022 02 15;94(2):720-728. Epub 2021 Nov 15.

Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, Delhi, India.

Nasopharyngeal carcinoma (NPC) is the most common malignant tumor of the nasopharynx. Although NPC is not endemic in India, higher incidences were observed in its North-Eastern regions particularly Sikkim, Nagaland, Manipur, and Mizoram. Early detection of NPC is difficult because the nasopharynx is not readily amenable to clinical examination and symptoms of NPC are nonspecific. The development of suitable biomarkers for early diagnosis of NPC as well as accurate monitoring of treatment response is needed urgently. In this exploratory pilot study, we have investigated the clinical significance of assessing plasma Epstein-Barr virus (EBV) DNA load at diagnosis and during treatment. We found that EBV DNA is detectable at diagnosis in the majority of patients with nonendemic NPC and the absolute copy number of circulating EBV DNA per milliliter increases progressively with the stage of the disease. The viral load declined significantly with induction chemotherapy and definitive chemoradiation but showed a sharp rise at relapse. Patients with EBV DNA levels ≥1500 copies/ml had a higher risk of disease progression or relapse when compared with patients who had EBV DNA <1500 copies/ml at baseline. Estimation of plasma EBV DNA may serve as an excellent noninvasive tool to monitor disease extent, response to therapy, and for better prediction of future relapse or progression-free survival in a nonendemic NPC patient population.
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http://dx.doi.org/10.1002/jmv.27440DOI Listing
February 2022

Human papilloma virus in the etiopathogenesis of allergic nasal polyposis: A prospective study.

Am J Otolaryngol 2022 Jan-Feb;43(1):103273. Epub 2021 Oct 20.

Department of Otorhinolaryngology and Head-Neck Surgery, AIIMS, New Delhi, India. Electronic address:

Purpose: To evaluate and compare the prevalence of high-risk HPV and low-risk HPV types in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) and healthy controls.

Materials And Methods: A prospective cohort study was conducted in a tertiary care hospital on the patients of CRSwNP undergoing surgical management. All patients underwent preoperative endoscopic evaluation and radiological assessment using NCCT of the nose and paranasal sinuses. The severity of the disease was graded using the Lund-Mackay score on NCCT. All patients underwent endoscopic polypectomy and the sample of tissues was sent for HPV DNA detection using Hybrid Capture II® technique. The clinicopathological characteristics of HPV positive and negative patients were compared.

Results: Sixty cases and 20 controls were included in the study. All controls were negative for HPV DNA. 27 patients (45%) had the presence of HPV DNA, out of which 23 had only LR-HPV and 1 had only HR-HPV types. Three patients had both HR-HPV and LR-HPV subtypes. There was a significant difference between the cases and controls for the presence of HPV DNA (p < 0.001). However, the patients with HPV-positive DNA in the nasal specimen did not differ significantly from HPV-negative patients in age, gender, or severity of the disease.

Conclusions: Human papillomaviruses may play a significant role in the etiopathogenesis of CRSwNP, however, do not impact the degree of sinus involvement.
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http://dx.doi.org/10.1016/j.amjoto.2021.103273DOI Listing
February 2022

TransOral UltraSonic Surgery (TOUSS) assisted supraglottic laryngectomy: Expanding the spectrum of endoscopic head and neck surgeries.

Oral Oncol 2021 11 19;122:105562. Epub 2021 Oct 19.

Department of Otorhinolaryngology and Head-Neck Surgery, Teaching Block, All India Institute of Medical Sciences, New Delhi 110029, India.

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http://dx.doi.org/10.1016/j.oraloncology.2021.105562DOI Listing
November 2021

Cord medialisation in unilateral vocal fold paralysis improves forced vital capacity.

Clin Otolaryngol 2022 01 14;47(1):115-119. Epub 2021 Oct 14.

Department of Otolaryngology & Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.

Objectives: The lateralised vocal fold of unilateral vocal fold paralysis (ULVFP) is unphysiological for expiration wherein vocal folds normally adduct to increase expiratory resistance and prevent small airway collapse. ULVFP may therefore impair ventilatory function and ventilatory volume. This study seeks to test whether vocal fold medialisation improves forced vital capacity (FVC).

Design: Prospective inception cohort intervention study.

Setting: Academic Tertiary Care Institution.

Participants: Twenty-five patients of ULVFP with a phonatory gap ranging from 2 to 6 mm.

Main Outcome Measures: Vocal fold medialisation was undertaken with autologous fat injection. Forced vital capacity (FVC) assessments by spirometry were undertaken pre-treatment and 1-month post-treatment.

Results: Improvement in FVC was noted in all patients with the quantum of improvement ranging from 0.1 to 0.6 litres. Mean FVC improved from 3.10 L pre-injection to 3.45 L post-injection. (p < .001). A moderate correlation was noted between the degree of medialisation and improvement in FVC (r = .33, Pearson's correlation coefficient).

Conclusions: Objective improvement in FVC is consistently noted in post vocal fold medialisation for ULVFP and is probably mediated by increased glottic expiratory resistance and consequent improvement in intrinsic PEEP.
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http://dx.doi.org/10.1111/coa.13866DOI Listing
January 2022

Head and Neck Surgery During COVID-19 Pandemic: Experience from a Tertiary Care in India.

Indian J Surg Oncol 2021 Dec 12;12(Suppl 2):279-289. Epub 2021 Sep 12.

Department of Otorhinolaryngology and,Head and Neck Surgery, All India Institute of Medical Sciences, 110029 New Delhi, India.

Head and neck pathologies requiring surgical intervention are considered a high-risk subsite in the context of COVID-19 pandemic by virtue of its close proximity to the mucosa of the upper aerodigestive tract. Retrospective review of all head and neck surgical procedures is undertaken during the pandemic from 23rd April 2020 to 30th September 2020. One hundred procedures were performed on 98 patients. COVID-19 status determined by SARS-Cov-2 RT-PCR at baseline was negative for 81, positive in 8 and unknown in 11. The RT-PCR negative subgroup included 40 diagnostic procedures and 41 ablative and or reconstructive procedures for head and neck neoplasms. None of the patients or health-care workers converted to COVID-19-positive status during the duration of the hospital stay. There were no cases with 30-day mortality. Clavien-Dindo grading for postoperative complications was as follows: 1-4, 2-12, 3a-2, 3b-1. Eleven patients with unknown COVID-19 status at baseline underwent emergency tracheostomy in a COVID-19 designated operating room for upper airway obstruction secondary to head and neck cancer. Of the 8 procedures conducted on known cases of COVID-19, 6 were tracheostomies performed for COVID-19 ARDS. The rest were maxillectomy for acute invasive mucormycosis and incision and drainage for parotid abscess. A matched-pair analysis was performed with similarly staged historical cohort operated during January to December 2016 to compare peri-operative complication rates (Clavien-Dindo Score). Incidence of complication with higher Clavien Dindo Score (>/=3a) was found to be lower in those patients operated during the pandemic (p=0.007). By meticulous preoperative COVID-19 screening and isolation, head and neck surgical procedures can be continued to avoid delay in diagnosis and treatment without jeopardising the risk of transmission of COVID-19 to the patients or health-care workers.
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http://dx.doi.org/10.1007/s13193-021-01424-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8435157PMC
December 2021

Revisiting rhino-orbito-cerebral acute invasive fungal sinusitis in the era of COVID-19: pictorial review.

Emerg Radiol 2021 Dec 31;28(6):1063-1072. Epub 2021 Aug 31.

Department of Otorhinolaryngology & Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India.

COVID-19 patients have been found to have an increased incidence of superadded fungal infections because of multiple factors such as impaired cell-mediated immunity, immunosuppressive therapy, and coexistent diabetes mellitus. Recently, there has been a significant rise in the COVID-19-associated mucormycosis and aspergillosis cases involving the sinonasal cavity and the lungs. Rhino-orbito-cerebral acute invasive fungal rhinosinusitis (AIFR) is a potentially life-threatening, invasive fungal infection. Early diagnosis followed by prompt medical management and surgical intervention is crucial for patient survival. The role of cross-sectional imaging (CT/MRI) is not only to suggest a diagnosis of invasive fungal sinusitis but also to delineate the complete extent of disease. Mapping the extent of orbital and intracranial disease has prognostic as well as management implications, as involvement of these sites marks a worse prognosis. A stepwise approach to evaluation of imaging of AIFR along with a pictorial depiction of the key imaging findings is presented.
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http://dx.doi.org/10.1007/s10140-021-01980-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8406018PMC
December 2021

Efficacy of Ultrasound-Guided Intermediate Cervical Plexus Block by Anterior Route for Perioperative Analgesia in Robotic Thyroidectomy by Retroauricular Approach: A Case Series.

A A Pract 2021 Aug 12;15(8):e01501. Epub 2021 Aug 12.

Otolaryngology & Head Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.

Retroauricular or facelift approach for robotic thyroidectomy involves a long incision with extensive subcutaneous dissection causing severe pain and discomfort. Multimodal analgesic regimen with inclusion of intermediate cervical plexus block by anterior route provided excellent perioperative analgesia without affecting recurrent laryngeal nerve monitoring in 10 cases. All the patients were monitored with bispectral index (maintained 40-60) and extubated on table. Median numeric pain rating scale score in 24 hours postoperatively was 3. None of the cases had any significant complications on follow-up.
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http://dx.doi.org/10.1213/XAA.0000000000001501DOI Listing
August 2021

The impact of pediatric tracheostomy on the quality of life of caregivers.

Int J Pediatr Otorhinolaryngol 2021 Oct 27;149:110854. Epub 2021 Jul 27.

Department of Otolaryngology, Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.

Objective: Pediatric tracheostomy is a challenge in otolaryngology practice and it is associated with greater morbidity and mortality than in adults; hence, constant vigilance by the designated family caregiver is critical. This study was designed to assess the impact of on quality of life of caregivers in a homecare setting as a result of the presence of child with a tracheostomy.

Methods: This was a combined retrospective and prospective cohort study with caregivers of children younger than 16 years who had undergone a tracheostomy, had been discharged home with a tracheostomy tube and completed 6 months of domiciliary tracheostomy care. The consenting primary caregivers were assessed for their quality of life based on the PedsQL v 4.0 questionnaires across various domains.

Results: We identified the primary caregivers of 85 children who had undergone a tracheostomy during the study period. The children's median age was 3.5 years (range, 9 months to 14 years). The mean caregiver health-related quality of life (HRQOL) score was 59.3, the mean family functioning score was 62.8, and the mean total family impact score was 54.7 with relative deficits seen in caregiver's social functioning (56.9) and emotional functioning (53.2). Good or average quality of physical and social function was seen among 74 % and 65 % of caregivers respectively while only 55 % were reported having good or average emotional function. Emotional disturbance, interfering with everyday family activities, and sleep disturbance were the major concerns among caregivers.

Conclusion: The biopsychosocial consequences of caring for a child with a tracheostomy are profound for the family, affecting the quality of life of caregivers and adding to the emotional and social burden of the child's family.
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http://dx.doi.org/10.1016/j.ijporl.2021.110854DOI Listing
October 2021

Impact of skin invasion on long-term survival outcomes in gingivobuccal complex carcinoma.

Acta Otorrinolaringol Esp (Engl Ed) 2021 Jul-Aug;72(4):205-211

Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Gingivo-buccal complex cancers (GBCC) have an aggressive clinical course in the presence of skin and bone involvement.

Objective: This study intends to analyze the clinico-pathological factors affecting local control and survival outcomes in GBCC.

Methods: This is a retrospective study conducted on 125 GBCC cases from January 2011 to April 2016.

Result: Univariate analysis revealed lymphovascular invasion (LVI) and skin involvement as predictors of poor overall survival (OS) and disease- free survival (DFS). Multivariate analysis showed skin involvement and LVI to be independent prognostic factors towards poor OS. Corresponding results in case of DFS showed skin involvement to be the single most important prognostic factor. With a median follow up of 24 months, the median survival of patients with skin involvement, skin and mandible invasion and isolated mandible invasion, respectively, were 18 months, 12 months and 22 months.

Conclusion: GBCC with skin involvement portends poor outcome in terms of survival. In the presence of skin invasion, treatment entails liberal soft tissue and bone margin followed by adjuvant treatment.
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http://dx.doi.org/10.1016/j.otoeng.2020.04.007DOI Listing
October 2021
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