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Mucormycosis or grimmer popular name, "black fungus" has evolved public concern in context of covid-19 pandemic, Covid Associated Mucormycosis (CAM) seen in Covid-19 pandemic and as a post covid sequelae. The present study was conducted to find out the incidence of the Mucormycosis, and to study its association with post-covid status and co-morbidities. A retrospective study conducted at tertiary care centre over a period of four months, involving all patients with mucormycosis of the paranasal sinuses suffering from or having a history of coronavirus disease. 59 patients had CAM, 47 patients had rhino-orbital Mucormycosis, followed by nasal and paranasal Mucormycosis in 8 patients, 3 patients with rhino-orbital-cerebral Mucormycosis, and one patient with pulmonary Mucormycosis. Diabetes mellitus was present in all 59 patients, 60.41% who had HbA1c > 10 (range 7-15), and 39.58% had HbA1c < 10 with range 6-13. Only 8.33% had controlled diabetes status, uncontroled hypertension and diabetes was seen in 34.02%. All patients were started with IV amphotericin B anti-fungal drug, and followed by oral posaconazole. Depending upon the extent of the disease surgical debridement was done in 52 patients. All patients had history of steroid intake. 7 mortality was there. Uncontrolled diabetes, over-zealous use of steroids, uncontrolled underlying primary disease or co-morbidities, prolonged hospitalization in intensive care unit or normal wards, and hyperventilation all these factors together aggravated the CAM. So it's proper management based on, prompt diagnosis, reversal of predisposing condition with proper medical and aggressive surgical debridement remain the corner stone for this deadly CAM.

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OBJECTIVES: Tumors involving the anterior portion of the maxillary sinus remain technically challenging to access via an endoscopic approach. The modified endoscopic Denker's (MED) procedure was recently introduced to address such lesions. We present a multicenter series of 58 patients with tumors involving the anterior maxillary sinus successfully resected using a MED procedure and present the clinical outcomes and complications. METHODS: A multi-institution retrospective chart review was performed on patients who underwent the MED approach for the management of tumors involving the anterior maxillary sinus from 2009 to 2020. Demographic data, pathology, surgical outcomes, and complications were reviewed. RESULTS: Fifty-eight patients were identified, including 34 (58.6%) male and 24 (41.4%) female patients. The most common pathologies included: inverted papilloma (n = 27; 46.6%), adenoid cystic carcinoma (n = 9; 15.5%), and squamous cell carcinoma (n = 8; 13.8%). Thirty-eight patients (65.5%) underwent MED alone, while 20 (34.5%) had combined expanded endonasal approaches for lesions extending beyond the maxillary sinus. All maxillary sinus lesions were successfully accessed with the MED procedure without the need for an additional approach. After a mean follow-up of 30 months (range, 1-127), 8 of 58 (13.8%) patients developed complications related to the MED, including epiphora requiring an additional procedure (n = 4; 6.9%), prolonged facial/palatal numbness (n = 3; 5.2%), severe epistaxis (n = 1; 1.7%), and vestibular stenosis (n = 1; 1.7%), the latter of which occurred following postoperative radiation. CONCLUSION: The MED procedure is a safe and highly effective approach for benign and malignant tumors involving the anterior maxillary sinus. However, patients should be counseled preoperatively on potential complications including the risk of facial numbness and epiphora.

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Introduction: Recent advances in endoscopic paraphernalia have brought the once intricate anterior lateral wall of maxilla, within reach of the endoscopic surgeon. Endoscopic modified Denker's approach provides another route to reach the indiscernible sites of maxillary & other paranasal sinuses along with PPF (pterygo-palatine fossa)/ITF (infra-temporal fossa) region. This approach has been widely used Pan-India during the Post-Covid Mucormycosis Epidemic, in our country. As this approach mandates sacrifice of nasolacrimal duct, the suspicion in some quarters about post-op fibrosis and eventually obstruction of lacrimal drainage is genuine. Aim: The aim is to understand the legitimate effect of this approach on lacrimal drainage pathway and to determine the need for modification in this approach, like stenting the NLD. Materials and Methods: In total, 100 patients who underwent endoscopic modified Denker's maxillectomy for invasive rhino-orbito-cerebral mucormycosis were included in study. The patency of lacrimal drainage was checked by doing lacrimal sac syringing in each patient. Proportion of patients showing obstruction of lacrimal pathway was calculated. Result: The ratio of lacrimal obstruction was found to be 9%. Hence, endoscopic modified Denker's approach for lesions involving anteroinferior and anterolateral part of maxillary sinus does not cause significant obstruction in the lacrimal drainage pathway.

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BACKGROUND: Both the endoscopic transnasal Denker's and prelacrimal approaches provide surgical access to the pterygopalatine fossa (PPF) and infratemporal fossa (ITF). OBJECTIVES: This study compares the potential maximum exposure of the PPF and ITF and quantifies the difference in surgical freedom via endoscopic Denker's and prelacrimal approaches. METHODS: Six cadaveric specimens (12 sides) were dissected using a prelacrimal approach on one side and an endoscopic Denker's approach on the contralateral side. The contents of the PPF and ITF were sequentially exposed. Surgical freedom for each corridor was subsequently calculated. RESULTS: This study confirms that both the prelacrimal and Denker's approaches provide adequate exposure of the PPF and ITF. The maximum exposure boundaries were similar for both approaches, including the middle cranial fossa superiorly, floor of the maxillary sinus inferiorly, zygomatic arch and temporomandibular joint laterally, and post-styloid space posteriorly. However, the data revealed a statistically significant difference (p < 0.05) regarding the surgical freedom of the prelacrimal (388.17 ± 32.86 mm2) and the endoscopic Denker's approaches (906.35 ± 38.38 mm2). CONCLUSION: When compared with an endoscopic Denker's approach, a prelacrimal approach seems to achieve a similar extent of exposure (ie, visualization) of the PPF and ITF. Nonetheless, the endoscopic Denker's approach offers superior surgical freedom; thus, it is preferred for the management of complex lesions which requires increased instrument maneuverability with a 3- or 4-handed technique.

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Objective This study was aimed to propose an expanded endoscopic-assisted lateral approach to the infratemporal fossa (ITF) and compare its area of exposure and surgical freedom with the endoscopic endonasal transptergyoid approach (EETA). Methods Anatomical dissections were performed in five cadaver heads (10 sides). The ITF was first examined through the endoscopically assisted lateral corridor, herein referred to as the endoscopic-assisted transtemporal fossa approach (TTFA). After that, the EETA was performed and coupled with two sequential maxillary procedures (medial maxillectomy [MM], and endoscopic-assisted Denker's approach [DA]). Using the stereotactic neuronavigation, measurements of the area of exposure and surgical freedom at the foramen ovale were determined for the previously mentioned approaches. Results Bimanual exploration of the ITF through the endoscopic-assisted lateral approach was achieved in all specimens. The DA (729 ± 49 mm 2 ) provided a larger area of exposure than MM (568 ± 46 mm 2 ; p < 0.0001). However, areas of exposure were similar between the DA and the TTFA (677 ± 35 mm 2 ; p = 0.09). The surgical freedom offered by the TTFA (109.3 ± 19 cm 2 ) was much greater than the DA (24.7 ± 4.8 cm 2 ; p < 0.0001), and the MM (15.2 ± 3.2 cm 2 , p < 0.0001). Conclusion The study demonstrates the feasibility of the proposed approach to provide direct access to the extreme extensions of the ITF. The lateral corridor offers an ideal working area in the posterior compartment of the ITF without crossing over important neurovascular structures. The new technique may be used alone in selected primary ITF lesions or in combination with endonasal approaches in pathologies spreading laterally from the nose or nasopharynx.

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The infratemporal fossa (ITF) is bounded superiorly by the skull base, specifically the greater wing of the sphenoid, which contains foramen ovale. It is bordered posteriorly by the temporal bone, including the petrous portion of the carotid canal, anteriorly by the posterior wall of the maxillary sinus, laterally by the mandible, and medially by the pterygoid body and lateral pterygoid plate.1-3 In this video, we report a case of a rare, exclusively extradural, schwannoma originating from the third division of the trigeminal nerve with a widened foramen ovale at the skull base. The tumor filled the ITF and extended laterally just through the sigmoid notch of the mandible. The patient complained of left cheek and lower jaw numbness and intermittent left jaw spasms. The tumor was deemed appropriate for endoscopic resection. To access the ITF, left-sided endoscopic sinus surgery, a modified endoscopic Denker's approach,4 and posterior nasal septectomy were first performed. A nasoseptal flap was also harvested in case an intraoperative cerebrospinal fluid (CSF) leak required repair. Dissection was carried out through the posterior wall of the maxillary sinus and pterygopalatine fossa to reach the ITF. Tumor resection was achieved through a 2-surgeon, 4-handed approach in which appropriate traction and countertraction were carefully applied to tease the tumor away from the skull base and dehiscent carotid canal. No CSF leak or carotid injury occurred, and the posterior maxillary sinus wall defect was repaired with the nasoseptal flap. The patient did well postoperatively. The patient consented to the procedure in a standard fashion.

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BACKGROUND: The infratemporal fossa (ITF) represents an area densely packed with neurovascular structures within irregular boundaries. The goal of this study was to classify the ITF into zones corresponding to its anatomical spaces and the order in which they are encountered during an endonasal approach (anteroposterior axis). METHODS: Six cadaveric specimens (12 sides) with injected colored latex were dissected. Following an endoscopic medial maxillectomy and Denker's approach, a progressive exploration of the masticator space and upper parapharyngeal space was completed. A classification of the ITF based on well-defined spaces was ascertained. RESULTS: The ITF was divided into five zones: Zone 1 (retromaxillary space)-space lying between the posterolateral wall of the maxillary sinus and the temporalis and pterygoid muscles. Zone 2 (superior interpterygoid space)-area including the superior head of the lateral pterygoid muscle, V3 , and foramen ovale. Zone 3 (inferior interpterygoid space)-includes the inferior head of lateral pterygoid muscle, medial pterygoid, and temporalis muscles, and the space enclosed by these muscles. Zone 4 (temporo-masseteric space)-space lateral to the temporalis muscle (comprising fat mostly). Zone 5 (tubopharyngeal space)-includes the Eustachian tube, tensor, and levator veli palatini muscles, and structures in upper parapharyngeal space. CONCLUSION: The ITF can be visualized as five zones based on spaces enclosed by the masticator muscles and upper parapharyngeal structures. This novel classification system is useful to guide endoscopic approaches to the ITF, while decreasing the potential for injury of neurovascular structures and pterygoid muscles.

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BACKGROUND: Addressing anterior maxillary sinus pathology endoscopically that is inaccessible with an endoscopic modified medial maxillectomy requires either a prelacrimal approach (PLA) or an endoscopic Denker's approach (EDA). The PLA involves removing the medial wall of the prelacrimal recess (PLR), which is the bone between the pyriform aperture (PA) and nasolacrimal duct (NLD), from nasal floor to orbital floor. The PLA preserves the inferior turbinate and NLD, whereas both are sacrificed during an EDA. The purpose of this computed tomography (CT)-based study was to determine the anteroposterior and superoinferior dimensions of the medial wall of the PLR. METHODS: One hundred thirty-one triplanar sinus CT scans of patients with various rhinologic diseases, but with intact bony PLR walls, were reviewed to assess dimensions of the medial wall of the PLR. The anteroposterior distances from the PA to the inferior-most, middle, and superior-most aspects of the NLD were measured. The height from the nasal floor to orbital floor was also measured. Combining left and right sides, there were 262 measurements. RESULTS: The anteroposterior distances between the PA and the NLD were as follows: inferior: mean, 8.4 mm (standard error [SE], 0.2; range, 1.9-14.2); middle: mean, 7.6 mm (SE, 0.2; range, 0-13.6); and superior: mean, 5.5 mm (SE, 2.5; range, 0-11.9). The mean height of the medial wall of the PLR was 26.5 mm (SE, 0.2; range, 18.5-39.9). CONCLUSION: The anteroposterior and superoinferior dimensions of the medial wall of the PLR are variable, with the anteroposterior dimension being widest inferiorly. Its dimensions should be evaluated preoperatively when considering endoscopic approaches to or through the anterior maxillary sinus.

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The aim of this study is to emphasise the importance of preserving the anterior facial skeleton in angiofibroma surgery and to introduce a new approach by which tumors with far lateral extensions can be operated upon successfully without disruption of the anterior facial skeleton. This is a prospective study conducted at a tertiary referral academic centre. Two patients with extensive juvenile nasopharyngeal angiofibroma with far lateral extensions were recruited and they underwent surgery between July and August 2016. Both patients were not embolised prior to surgery. Complete tumor removal was achieved in both cases without any evidence of recurrence of disease. The facial contour was well maintained. They are under regular follow-up at our centre, having completed their third 3 monthly follow-up. The main outcome measures are preservation of the anterior facial skeleton and complete tumor removal. The Four-Port Bradoo Technique allows for maximum access to the angiofibroma whilst maintaining the anterior facial skeleton, thus ensuring complete removal with minimal morbidity to the patient.