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Purpose Our aim was to assess the sinonasal magnetic resonance imaging (MRI) features of acute invasive fungal rhinosinusitis (AIFRS) in coronavirus disease (COVID)-associated mucormycosis (CAM) and to correlate these with histopathology and patient outcome in terms of duration of hospital stay and survival at 10 weeks. Methods Twenty patients with histopathologically confirmed sinonasal CAM underwent MRI (including postcontrast T1-weighted and diffusion-weighted imaging). Histopathological findings (presence of coagulative necrosis, granulomatous reaction, and fungal burden) were recorded and all patients were followed up at 6 and 10 weeks. Statistical analysis was done using chi-square test and Fischer's exact test. Results Enhancement patterns seen in our subjects included homogeneous, heterogeneous, and lack of contrast enhancement (LOC), with LOC being the most common (65%). Diffusion restriction was found in 90% patients. Statistically significant correlation was found between LOC pattern and presence of coagulative necrosis (p-value = 0.007), extent of fungal hyphae (p-value = 0.047), and duration of hospital stay (p-value = 0.004). Restricted diffusion was also seen to correlate with a high fungal load (p-value = 0.007). Conclusion Our study describes the MRI findings of AIFRS in CAM and highlights the imaging features which may be surrogate markers for coagulative necrosis and fungal burden.

Recent pandemic of COVID19 infection has witnessed a re-emergence of invasive fungal sinusitis especially of the Mucor species, which has been a rare entity in the pre covid era. Covid associated mucormycosis (CAM) is one of the dreaded and fatal complications which has surfaced up and early diagnosis is critical for management and survival .It is identified to affect both subset of patients, those with active COVID-19 infection and those who have recovered from the disease in the last 4-6 weeks. Imaging features suggestive of early invasion with supportive imaging examples and relevance of these findings in clinical decision making is presented.This paper reviews the various imaging signs of early invasion in CAM A comprehensive checklist for clinically relevant and quick reporting is also presented.Emphysematous or ulcerative mucosal changes in the nasal cavity is an early imaging feature of CAM. Periantral soft tissue and soft tissue within the pterygopalatine fossa are important imaging signs to indicate extrasinus invasion. Disease within pterygopalatine fossa may lead to multidirectional spread and is an important check site. These findings are seen even in absence of bony erosions owing to the neurovascular spread of disease. Intra orbital and intracranial extensions were found to be fairly common and must be sought for.The knowledge of early subtle signs of CAM on imaging can aid in prompt diagnosis of this fatal entity in the pertinent clinical setting. Imaging signs of spread of disease and delineation of its extent as inferred from CT imaging aids in prognosis and appropriate surgical management.

Congenital aural atresia (CAA) is characterized by hypoplasia or aplasia of external auditory canal associated with auricular deformity. It also embodies a spectrum of temporal bone abnormalities including anomalies of middle ear, ossicles, facial nerve, oval window, round window, mastoid pneumatization, temporomandibular joint and occasionally inner ear and vascular anomalies. The management in such patients is variable and consists of rehabilitative hearing aids or surgical correction depending on various patient factors like associated temporal bone abnormalities, degree of hearing impairment and laterality. Surgical management if planned, depends on the extent of associated temporal bone anomalies and hence necessitates comprehensive knowledge about the normal and abnormal anatomy of these structures. High resolution computed tomography (HRCT) is the optimal investigation which provides required anatomical information and plays a pivotal role in deciding the management strategy. This pictorial review aims to review the spectrum of anomalies involving critical structures in CAA on HRCT along with their clinical significance.

The coronavirus disease 2019 (COVID-19) infection caused by the novel severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is associated with a wide range of disease patterns, ranging from mild to life-threatening pneumonia. COVID-19 can be associated with a suppressed immune response and/or hyperinflammatory state due to cytokine storm. Reduced immunity, combined with steroid usage to prevent cytokine storm along with various pre-existing co morbidities can prove to be a fertile ground for various secondary bacterial and fungal infection, including mucormycosis. Diagnosis of mucor is a challenging task given high negativity rate of various detection methods. While histopathology is considered the gold standard, the acquisition of necessary tissue biopsy specimens requires invasive procedures and is time consuming.In this study various methods of mucor detection, like conventional cytopathology (CCP), liquid-based cytology (LBC, BD SurepathThis study showed that LBC has sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 72.4%,100%,100% and 38.4% respectively.This study showed that, liquid-based cytology (LBC) can be a rapid and effective alternative to histopathology in mucor diagnosis.

To correlate the clinical, radiological, and histopathological features in Covid-associated Rhino-orbito-cerebral mucormycosis cases presenting with acute visual loss.Cross-sectional study.Covid-associated Rhino-orbito-cerebral mucormycosis cases with unilateral visual loss, planned for exenteration, underwent orbital and ophthalmological ocular examination. The available radiological sequences, doppler ultrasonography and histopathology findings were correlated with clinical manifestations.The median age was 51 years and the male: female ratio was 3:1. All except one presented with unilateral ophthalmoplegia. The ocular media were hazy in 2 eyes. In 8 eyes, retinal changes were suggestive of occlusion of CRA (6), combined occlusion of CRA and central retinal vein (1), and myopic degeneration with hypertensive retinopathy (1). The contralateral eye showed retinal ischemic changes in one patient. Radiological imaging showed orbital apex involvement in the 10 affected eyes and one contralateral eye. Ipsilateral cavernous sinus thrombosis, diffusion restriction on MRI of optic nerve, internal carotid artery narrowing/thrombosis, and cortical watershed infarcts were seen in 8, 4, 4, and 2 cases, respectively. The blood flow in CRA and ophthalmic artery was absent or reduced in all the 10 affected eyes and in 1 contralateral eye. On histopathology, orbital fat necrosis, fungal hyphae, acute inflammation, granuloma formation, ischemic thrombosis of ophthalmic artery was observed in 10 specimens. CRA was patent in 9 and thrombosed in 1 eye. Optic nerve was ischemic in 8 and viable in 2 eyes.Acute visual loss in ROCM cases is associated with orbital apex involvement and thrombotic ischemia of ophthalmic artery. Cessation of flow in CRA possibly occurs secondary to ophthalmic artery thrombosis.

ObjectiveMucormycosis is a rapidly progressive and fulminant fungal infection mainly affecting the nose and paranasal sinuses and often requiring aggressive surgical debridement, which commonly includes inferior maxillectomy. Conventional inferior maxillectomy involves removal of the bony hard palate and its mucoperiosteum. This can lead to formation of an oroantral fistula and thereby increase the morbidity in these patients leading to prolonged rehabilitation. Subperiosteal inferior maxillectomy involves sparing of the uninvolved mucoperiosteum of the hard palate. This flap is used for closure of the oroantral fistula, which preserves the functional capabilities of the patient, such as speech, mastication and deglutination.MethodThis case series describes the experience of using the technique of mucosa-preserving subperiosteal inferior maxillectomy in five patients with mucormycosis.ResultsWith the technique used in this study, complete oronasal separation was achieved in all six patients. The overall surgery time was also decreased when compared with free tissue transfer. Patients also did not have to bear the weight of prosthesis.ConclusionMucoperiosteal palatal flap-preserving subperiosteal inferior maxillectomy is an excellent approach for all patients with mucormycosis and healthy palatal mucosa.

This study was designed to study the impact of menopause on voice quality. Cross-sectional Observational study with a total of 100 subjects. All subjects underwent biochemical analysis which included thyroid function tests, estrogen levels, progesterone levels and underwent voice analysis using the VAUGHMI voice analyser software. 50 postmenopausal females as cases and 50 premenopausal females as controls were taken for the study. The females were of the age group 35–55 yrs in order to remove age as confounding factor. The primary outcome measure was Total score, calculated based on harshness, hoarseness and breathiness. The postmenopausal females had a poorer voice quality than the premenopausal females (Total score 1.62 vs 2.48, p

BackgroundThere has been a recent deluge of coronavirus disease 2019 associated mucormycosis in our country. It affects the paranasal sinuses; however, it has a rapid extrasinus progression (the orbit being most common), which can be fatal if not detected early. It may meander into the orbit through various foramina without frank bone destruction.MethodsThis paper reviews the various gateways of the spread of coronavirus disease 2019 associated mucormycosis to the orbit, even before advent of bone destruction or ocular symptoms. Plausible pathways of invasion and subtle imaging findings are depicted, to enable an early diagnosis.ResultsRelevant anatomy and imaging examples have been illustrated to familiarise the surgeons with various routes of coronavirus disease 2019 associated mucormycosis spread to the orbit. Emphasis is laid on searching for subtle imaging findings for the detection of early orbital invasion.ConclusionEarly detection and extension of coronavirus disease 2019 associated mucormycosis is facilitated by knowledge of its gateways of spread, which aids the surgeon in prognostication and planning of the surgical approach.

BACKGROUND. Chronic rhinosinusitis (CRS) is one of the most common health problems in adults, which not only causes physical symptoms, but also results in functional and emotional impairment. The aim of the present study was to investigate the effect of functional endoscopic sinus surgery (FESS) on SNOT-22 in cases of chronic rhinosinusitis. MATERIAL AND METHODS. A total of 50 patients, between 18-60 years of age, who had taken treatment for CRS but found no improvement, were enrolled in the study. Before surgery, all patients were asked to fill the SNOT-22 form, the CT score was evaluated, and FESS was performed. A reevaluation with SNOT-22 questionnaire was performed 10 days, 1 and 3 months after surgery. The preoperative and postoperative scores and change score were calculated. RESULTS. The initial preoperative mean score was 39.96±13.41. The percentage decrease in symptom score on the 10th day, the first and third month postoperatively was 42%, 74% and 91% respectively. Males had scored higher as compared to females. There was no correlation between the CT score and SNOT-22 score. Rhinological symptoms scored more than 74% in chronic rhinosinusitis cases. CONCLUSION. SNOT-22 can be used in routine clinical practice to inform clinicians about a full range of problems associated with chronic rhinosinusitis. Responses on the instrument can help focus the clinical encounter. It can also aid researchers in assessing the degree and effect of rhinosinusitis on health status, QoL and to measure treatment response.

ObjectiveTo compare experts’ perceived usefulness of audit filters from Ghana, Cameroon, WHO and those locally developed; generate context-appropriate audit filters for trauma care in selected hospitals in urban India; and explore characteristics of audit filters that correlate to perceived usefulness.DesignA mixed-methods approach using a multicentre online Delphi technique.SettingTwo large tertiary hospitals in urban India.MethodsFilters were rated on a scale from 1 to 10 in terms of perceived usefulness, with the option to add new filters and comments. The filters were categorised into three groups depending on their origin: low and middle-income countries (LMIC), WHO and New (locally developed), and their scores compared. Significance was determined using Kruskal-Wallis test followed by Wilcoxon rank-sum test. We performed a content analysis of the comments.Results26 predefined and 15 new filter suggestions were evaluated. The filters had high usefulness scores (mean overall score 9.01 of 10), with the LMIC filters having significantly higher scores compared with those from WHO and those newly added. Three themes were identified in the content analysis relating to medical relevance, feasibility and specificity.ConclusionsAudit filters from other LMICs were deemed highly useful in the urban India context. This may indicate that the transferability of defined trauma audit filters between similar contexts is high and that these can provide a starting point when implemented as part of trauma quality improvement programmes in low-resource settings.

Juvenile nasopharyngeal angiofibroma(JNA) are highly vascular benign tumours originating in the sphenopalatine fossa and may extend to the pterygopalatine fossa, paranasal sinuses, and nasal cavity. The management of JNA has evolved greatly with development of endoscopy. Treatment modality has changed from open approach to endoscopic approach due to various advantages offered by the endoscopic approach. Bleeding during the surgery can compromise the exposure and surgical excision of JNA endoscopically. There have been many techniques to decrease intraoperative bleeding including external carotid ligation, hypotensive anaesthesia and more recently embolization of the feeding vessels. Embolization of the tumour has made the endoscopic excision of JNA easier because of less bleeding. This study was taken to find out the outcomes of surgical excision of JNA after embolization.We retrospectively reviewed 22 histopathological proven JNA cases that underwent preoperative embolization followed by resection during the period of June 2015 to December 2020 in our tertiary care hospital. From the records demographic, clinical, radiological imaging (CECT nose and PNS), angiographic, pre-operative embolization and operative details were evaluated.In the present study a total of 22 cases of angiofibroma were taken up for surgical excision after embolization. A complete endonasal endoscopic resection could be done in 21/22 cases with average operative time of 141 minutes (80 minutes-190 minutes range). The mean blood loss during surgery was 1163 ml (Range 500 ml- 1900 ml). In 7/22 (31.81%) subjects required intraoperative blood transfusion. No perioperative surgical complications occurred.Endoscopic excision of JNA has now become the primary operative technique and pre operative embolization in such cases can reduce the intraoperative time, blood loss and tumour relapse rate. It is a relatively safe procedure in a hand of an expert and must be done where ever available.

Introduction Complications during and after dissection of level IIb lymph nodes include spinal accessory nerve (SAN) dysfunction, which results in the limitation of shoulder movements and, thus, hurts the quality of life. The current study aims to know the occurrence of level IIb lymph node positivity in tongue carcinoma. Methods This cross-sectional study was conducted from January 2019 to December 2019 in a tertiary care center in North India. Adult cases with primary ulcer-proliferative growth over the lateral border of the tongue were included in the study. The level IIb lymph node positivity from the postoperative histopathology report was the primary outcome measure of this study. To investigate the potential association of tumor size on level IIb lymph node positivity, we compared the maximum tumor dimensions among the level IIb lymph node-positive and -negative groups. In addition, to analyze the impact of the tumor's invasive nature on level IIb lymph node positivity, we compared the depth of invasion and proportion of cases with muscle involvement among the level IIb lymph node-positive and -negative groups. Lastly, to investigate their concurrent occurrences, we compared the number of level IIb lymph node-positive cases among the level IIa lymph node-positive and -negative groups. Results A total of 39 patients fulfilling the inclusion criteria were included in the study. Only six had positive level-IIb lymph nodes. No significant associations of tumor size, invasion depth, muscle invasion, or involvement of level IIa lymph nodes with the positivity of level IIb lymph nodes were found. However, only three were level IIb lymph node-positive in 28 level IIa lymph node-negative cases. Conclusion Considering the low risk of isolated level IIb lymph node positivity in level IIa lymph node-negative cases, the dissection of level IIb nodes could be omitted during the surgical excision of the tumor. However, radiological investigations detecting metabolic activity should be used in the preoperative period and postoperative follow-up to detect early lymph node involvement and disease recurrence.

Objectives The aim of this study was to evaluate diffusion-weighted imaging (DWI) in comparison with morphologic magnetic resonance imaging (MRI) in differentiating among odontogenic keratocyst (OKC), unicystic ameloblastoma (UAB), and dentigerous cyst (DC). Study Design Contrast-enhanced MRI, including DWI, was performed on 27 patients with the 3 lesions. Signal intensity characteristics were evaluated on T1- and T2-weighted MRI. The apparent diffusion coefficient (ADC) cutoff value to most effectively differentiate among the 3 lesions was calculated with receiver operating characteristic analysis. Results In total, 17 OKCs, 5 UABs, and 5 DCs were diagnosed histologically. There were no significant differences among them in signal intensity on T1- or T2-weighted images (P ≥ .13). On DWI, 14 of 17 OKCs showed restricted diffusion with a mean ADC value of 0.954 × 10-3 mm2/s. All 5 UABs and all 5 DCs exhibited facilitated diffusion with ADC values ≥ 2.150 × 10-3 mm2/s. The ADC cutoff to differentiate OKCs from UABs was 2.137 × 10-3 mm2/s (P = .01); UABs from DCs was 2.422 × 10-3 mm2/s (P = .03); and OKCs from DCs was 2.347 × 10-3 mm2/s (P = .01). Conclusions Addition of diffusion-weighted sequences to MRI jaw protocols can assist in the characterization of OKCs, UABs, and DCs.

Malformations of the inner ear are an important cause of congenital deaf-mutism. Arrest in embryologic development of inner ear during various stages gives rise to the variety of malformations encountered. Current treatment options include hearing aids, cochlear implants, and auditory brainstem implants (ABI). With the advent of cochlear implant surgery and ABI, decent functional outcomes can be obtained provided such cases are diagnosed correctly and timely. To that end, high-resolution computed tomography (HRCT) has a fundamental role in the assessment of these conditions, ably supplemented by magnetic resonance imaging (MRI). The purpose of this pictorial essay is to illustrate the imaging features of inner ear anomalies in children with congenital deaf-mutism as per the latest terminology and classification and provide an algorithmic approach for their diagnosis.

In patients with critical tracheal stenosis, particularly involving the lower part of trachea, a highly experienced team of anesthesiologists to tackle the difficulties of securing and maintaining the ventilation, cardiac surgeon who can swiftly establish cardiopulmonary bypass, an experienced surgeon for tracheal reconstruction are a prerequisite for managing these highly complex cases. The present paper describes three patients suffering from severe tracheal narrowing wherein spontaneous bag-mask ventilation was used for establishing cardiopulmonary bypass via mid-sternotomy as a rare life-saving procedure for urgent tracheal reconstructive surgery. A highly experienced team of anesthesiologists to tackle the difficulties of securing and maintaining the ventilation, cardiac surgeon who can swiftly establish CPB, and an experienced surgeon for tracheal reconstruction are a prerequisite for managing these highly complex cases. The present paper describes three patients suffering from severe tracheal narrowing wherein spontaneous bag-mask ventilation was used for establishing CPB via mid-sternotomy as a rare life-saving procedure for urgent tracheal reconstructive surgery.

Objective: To evaluate the utility of intraoral fine-needle aspiration cytology (FNAC) in diagnosis of minor salivary gland neoplasms (MSGN) with application of Milan system of reporting salivary gland cytopathology; keeping histopathology as gold standard and to detail the cytological findings of MSGNs. Method: Retrospective study between Jan 2008 and June 2017 (appro × 10 years) on the cytology of the minor salivary gland tumor along with the histopathological correlation. The relevant clinical data was collected from the medical record. Result: Sixty-four cases of MSGNs were included in the study. The histodiagnosis of the 41 were available. Twenty-one cases were diagnosed as malignant, while rest 20 cases were reported as benign. The most common tumor diagnosed was pleomorphic adenoma (PA) (50% cases), followed by mucoepidermoid carcinoma (14%) and adenoid cystic carcinoma (12.5%). The most common site of MSGT was found to be hard palate (44%), followed by soft palate (23%), floor of the mouth (12%), lip (11%), buccal mucosa (5%), and tongue (5%) with no gender predilection. Sensitivity of FNAC for detection of malignancy was 81% while specificity 95%. For malignancies, positive predictive value for malignancies was 17/18 (94.4%) and negative predictive value was 19/23 (82.3%). According to Milan system out of 21 cases in category IV B, 4 cases were found malignant (Category VI), while 1/18 case in category VI turned out to be nonneoplastic lesion (Category II). Conclusion: FNAC is imperative in early diagnosis and subsequent management of MSGNs

Objectives Nasal dermoids are rare developmental anomalies seen in children. This study reports our experience in a developing country of the clinical and radiological findings as well as the management of nasal dermoids. Methods A retrospective analysis was performed, from 2012 to 2017, for 10 patients admitted for the treatment of nasal dermoids at a tertiary care center. The clinical presentation, preoperative imaging (CT/MRI), surgical approach, intraoperative findings, complications and recurrence were reviewed. Results Ten patients were included in this study, 6 males and 4 females, with an average age of 10.2 years at the time of presentation. Three patients presented with a mass located on the nasal dorsum, 1 had a nasoglabellar mass, 2 patients had a mass located on the nasal dorsum with visible sinus, and 4 patients presented with a sinus on the nasal dorsum, in which 1 patient had a tuft of hair. CT was performed in all the cases. It was not suggestive of intracranial extension in 9 patients, and was non-diagnostic in one patient. Both CT and MRI were performed on 2 patients, with no evidence of intracranial extension. Surgical and radiological findings were concordant in 8 patients (80%). Conclusion Nasal dermoids require preoperative imaging and precise surgical planning to achieve complete removal.

Background The sinonasal region is affected by a variety of neoplasms. A differentiation between benign and malignant masses is essential both for management and prognostication. Morphological analysis often does not allow this differentiation. Objectives This article aims to assess the value of advanced MRI (diffusion [DWI] and dynamic contrast enhanced MRI [DCE-MRI]) in differentiation of benign and malignant sinonasal masses. Methods This prospective study included 40 patients with sinonasal masses who underwent advanced MR on 3T MR scanner. The lesions were analyzed based on morphological characteristics, qualitative, quantitative diffusion parameters, and time signal intensity curves. Apparent diffusion coefficient (ADC) values were acquired using b values of 50 and 1000 s/mm2. The accuracy of DWI, DCE-MRI, and combined DWI/DCE-MRI in differentiating benign from malignant sinonasal masses were analyzed. Results Perineural extension and growth pattern of the tumor were the best morphological discriminators. Mean ADC values for benign and malignant lesions were 1.675 ± 0.561 and 0.903 ± 0.405 × 10−3 mm2/sec, ,respectively. ROC revealed that ADC cutoff value of 1.005 × 10−3 mm2/sec provided an accuracy of 92.5% in differentiating benign from malignant masses ( P value Conclusion DWI has higher accuracy than DCE-MRI. Quantitative DWI is preferable over qualitative DWI. Accuracy of DCE-MRI can be increased by excluding vascular masses with characteristic imaging features. DWI and DCE-MRI have the highest accuracy when used in combination than either of them alone in differentiating benign from malignant sinonasal masses.

Ritu Arora,1 Ruchi Goel,1 Samreen Khanam,1 Sumit Kumar,1 Shalin Shah,1 Sonam Singh,1 Mohit Chhabra,1 Ravi Meher,2 Nita Khurana,3 Tanu Sagar,4 Suresh Kumar,5 Sandeep Garg,5 Jyoti Kumar,6 Sonal Saxena,4 Rashmi Pant7 1Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India; 2Department of Otorhinolaryngology, Maulana Azad Medical College, New Delhi, India; 3Department of Pathology, Maulana Azad Medical College, New Delhi, India; 4Department of Microbiology, Maulana Azad Medical College, New Delhi, India; 5Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India; 6Department of Radiodiagnosis, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India; 7Society for Health Education and Allied Research, New Delhi, IndiaCorrespondence: Ruchi GoelDepartment of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, 110002, IndiaTel +91 9811305645; +91-11-41440108Email gruchi1@rediffmail.comPurpose: To list the clinico-epidemiological profile and possible risk factors of COVID-19 associated rhino-orbital-cerebral mucormycosis (CA-ROCM) patients presenting to a COVID dedicated hospital during the second wave of COVID-19 in India.Patients and Methods: A cross-sectional, single-center study was done on 60 cases of probable CA-ROCM based on clinical features and supportive diagnostic nasal endoscopic findings and/or radiologic findings. Patients with recent or active COVID-19 were included. The demographic profile, clinical features, possible risk factors and diagnostic workup (microbiological, pathological and radiological) were analysed to identify the triggering factors for CA-ROCM.Results: The age of patients ranged from 29 to 75 years and male–female ratio was 3:1. The duration between the first positive COVID report and onset of CA-ROCM was 0 to 47 days. Forty-nine (81.66%) patients had a recent COVID infection and 11 (18.33%) had active COVID infection at presentation. Thirty-five patients (58%) had ocular/orbital involvement at presentation. In the affected eye, 10 had no perception of light and in the rest visual acuity ranged from log MAR 0 to +1.5. Ocular manifestations were ptosis (29), ophthalmoplegia (23), periocular tenderness and edema (33), proptosis (14), black discoloration of eyelids (3), facial palsy (3), endophthalmitis (4), retinal artery occlusion (8), disc edema (4) and disc pallor (5). Twenty-two (25%) patients had neither received steroids nor oxygen. Thirty patients (50%) were managed with oxygen while 38 patients (63.3%) with systemic steroids. The most common risk factor was diabetes in 59 patients. The average glycosylated hemoglobin (HbA1c) was 10.31 ± 2.59%. Systemic Amphotericin B was started in all the patients. Radical surgical debridement was performed in 12 patients and the remaining were planned.Conclusion: SARS-CoV-2 variant with accompanying glycaemic dysregulation was found to be the triggering factor for the epidemic of CA-ROCM.Keywords: COVID-19 treatment, CA-ROCM, orbital apex syndrome, ophthalmoplegia, retinal arterial occlusion, COVID-19 associated rhino-orbital-cerebral mucormycosis