Fibrolipoma presenting as a posterior nasal septum mass: a report of a unique case and review of the literature

Unilateral sinonasal mass presenting as nasal block is a common presentation but poses a diagnostic challenge. The differential diagnosis includes inflammatory polyps, benign and malignant sinonasal neoplasm. Fibrolipoma presenting in the sinonasal area is an uncommon pathology. As it is uncommon, there is potential for a misdiagnosis, unnecessary investigation and delay in the definitive treatment. We report a patient with a fibrolipoma originating from the posterior nasal septum. The diagnostic and surgical features of this unique case are discussed.

Aggressive primary sinonasal Ewing sarcoma with intraorbital and intracranial extension

Ewing sarcoma (ES) of the extraskeletal form is a rare occurrence and even rarer to manifest in the sinonasal tract. We describe a case of an advanced sinonasal ES with orbital and intracranial extension that was managed with chemotherapy and endoscopic surgery. Despite completing chemotherapy and surgical resection, the tumor progressed rapidly even before postoperative radiotherapy, and subsequently, she succumbed to death due to sepsis. We would like to discuss the management challenges, pitfalls, and surgical approach which may improve the outcome of this complicated disease.

Validity and Reliability Study of Bahasa Malaysia Version of Sino-Nasal Outcome Test 22 in Chronic Rhinosinusitis Patient

Background: Chronic rhinosinusitis (CRS) affects 14% of the general population. The SinoNasal Outcome Test 22 (SNOT-22) is a reliable instrument assessing the impact of CRS. This study aimed to examine the reliability and construct validity of the translated Bahasa Malaysia version of SNOT-22. Methods: This cross-sectional study was conducted in the Otorhinolaryngology clinic in Universiti Sains Malaysia (USM). Seventy CRS respondents and 39 healthy participants were included. The Bahasa Malaysia translated SNOT-22 (bmSNOT-22) was produced using rigorous forward and backward translation. Statistical analyses used included feasibility, Cronbach’s alpha, intraclass correlation coefficient, Pearson’s correlation coefficient and factor analysis. Results: The feasibility was 97.2% in the initial test and 100% in the retest. The Cronbach’s alpha was 0.89 in the initial test. The average intraclass correlation coefficient (ICC) was 0.90, indicating good test-retest reliability. The bmSNOT-22 discriminated between the control group and patients (t = 15.33; P < 0.001). Conclusion: The bmSNOT-22 is reliable, and validity established therefore recommended for Malaysia’s clinicians and researchers as a measurement tool for the outcome in sino-nasal disorders such as rhinosinusitis and nasal polyps.

Heterogeneity of Genetic Landscapes in Salivary Gland Tumors and Their Critical Roles in The Current Management

Salivary gland neoplasms (SGNs) are rare and heterogeneous tumors in the head and neck region. Although progress has been recently made in revealing the molecular landscape of salivary glands tumors, it is limited and appears to be the tip of the iceberg. Some genetic aberrations include chromosomal translocations, such as CRTC1/3-MAML2 in mucoepidermoid carcinoma, g MYB-NFIB gene fusions in adenoid cystic carcinoma, and PLAG1-HMGA2 gene changes in pleomorphic adenoma and carcinoma ex pleomorphic adenoma. These chromosomal translocations provide fresh insights into the molecular etiology of diverse SGNs and aid in their classification and in approaching treatment. In future, these genetic variations may serve as critical tools for diagnosing salivary gland tumors and optimizing the management as well as prognosis of patients. This review presents the most recent advances in the molecular pathology of salivary gland cancers, with an emphasis on distinguishing molecular features that can be used for optimizing current patient management.

Bilateral accessory middle turbinate presenting as double middle turbinate: A unique case report

Many anatomical variations of the middle turbinate (MT), including pneumatized, paradoxically curved, bifurcate, trifurcate, secondary, and accessory, have been described. The most common is pneumatized MT (concha bullosa), but other less common variations may also impact the outcome of clinical management. Anatomical variations of the MT, particularly with a concomitant deviated nasal septum, tend to obstruct the middle meatus leading to disruption of the normal sinus drainage and worsening the symptoms of rhinosinusitis. By recognizing the unique anatomical variant by endoscopy or imaging will help us to improve the management. We report an endoscopic presentation of a rare accessory MT.

Preliminary Comparison of Transseptal Microscopic Versus Endoscopic Transsphenoidal Surgery in a University Teaching Hospital

Background

Transsphenoidal surgery (TSS) is an increasing preferred treatment for sella lesions. In a university teaching hospital, the novel endoscopic TSS was adopted with ongoing resident teaching. We evaluated a single institutional series of preliminary comparisons of transseptal microscopic with endoscopic TSS.

Methods

A retrospective data analysis included 37 patients and 19 patients who underwent microscopic and endoscopic TSS, respectively. The demographic characteristics of the patients, intra-operative analyses, morbidity, mortality and visual assessments were included in this analysis.

Results

The study included 31 men and 25 women, and median age at surgery was 49 years old (range 14–70 years old). There were no differences between the rates of cerebrospinal fluid (CSF) fistula, sinus complications, anterior pituitary hormone deficiency and diabetes insipidus between the groups. Total length of stay and intensive care unit stay were similar between the groups. Patients who underwent endoscopic TSS were at significantly increased risk of epistaxis (P = 0.010), respiratory event (P = 0.014) and post-operative visual deterioration prior to discharge (P = 0.032).

Conclusion

Endoscopic TSS is a promising procedure that allows sufficient visualisation of the surgical field and adequate tumour removal. It is comparable to microscopic TSS but has a higher complication rate notably due to steep learning curve required to gain the expertise.

The Effect of Atopy on the Incidence of Osteitis in Patients with Chronic Rhinosinusitis

Background

Atopy may not contribute directly to the pathogenesis of chronic rhinosinusitis (CRS) and could be a coexisting disease, but it may play a disease-modifying role in CRS. The aim of this study was to determine the effect of atopy on the incidence of osteitis in patients with CRS.

Methods

A cross-sectional study at a tertiary center was conducted. Computed tomography of paranasal sinuses (CTPNS) of 75 CRS patients was analyzed. Skin prick test was used to determine the atopy among the CRS patients. The evaluation consisted of symptom score, Lund–Kennedy endoscopic score and CTPNS assessment by Lund Mackay (LM) staging system and Global Osteitis Scoring Scale (GOSS).

Results

About 54.7% of CRS patients had atopy (n=41), and 64% (n=48) had osteitis changes. No significant difference (p>0.05) was found for symptom and endoscopic scores in atopic and non-atopic CRS. Atopic and non-atopic CRS patients demonstrated comparable LM and GOSS scores (both p>0.05). Logistic regression analysis revealed that gender, nasal polyps and bronchial asthma were significantly associated with the incidence of osteitis. Significant correlation was found between LM and GOSS scores in atopic CRS (r=0.81, p<0.05). Correspondingly, both scores were found to be significantly correlated in non-atopic CRS (r=0.74, p<0.05).

Conclusion

Atopic sensitization has no effect on the incidence and severity of osteitis in patients with CRS. The present study suggests that osteitis occurs independently from the atopic pathway.

Efficacy and Safety of Bilastine in the Treatment of Allergic Rhinitis: A Systematic Review and Meta-analysis

Bilastine is a non-sedating second generation H1 oral antihistamine (OAH) for treating allergic rhinitis (AR) patients. The effect of bilastine has not previously been evaluated in a meta-analysis. The aim of this review was to determine the efficacy and safety of bilastine in treating AR. An electronic literature search was performed using Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Science Direct and Google Scholar up to March 2021. Randomized controlled trials comparing bilastine with placebo and standard pharmacotherapy were included. The included studies must have diagnosis of AR established by clinicians and the outcomes must have a minimum of 2 weeks of follow-up period. The primary outcomes assessed were total symptom score (TSS), nasal symptom score (NSS) and non-nasal symptom score (NNSS). The secondary outcomes were discomfort due to rhinitis, quality of life (QOL) and adverse events. The risk of bias and quality of evidence for all studies were appraised. The meta-analysis was done using Review Manager 5.3 software based on the random-effects model. The search identified 135 records after removal of duplicates. Following screening and review of the records, fifteen full-text articles were assessed for eligibility. Five trials involving 3,329 patients met the inclusion criteria. Bilastine was superior to placebo in improving TSS, NSS, NNSS, rhinitis discomfort score and QOL but has comparable efficacy with other OAHs in TSS, NSS, NNS, rhinitis discomfort score and QOL. There was no difference in adverse effects when bilastine was compared against placebo and other OAHs except for somnolence. Bilastine has fewer incidence of somnolence compared to cetirizine. The overall quality of evidence ranged from moderate to high quality. Bilastine is effective and safe in treating the overall symptoms of AR with comparable efficacy and safety with other OAHs except somnolence. Whilst bilastine has similar efficacy to cetirizine, somnolence is notably less in bilastine.

Pseudotumor of the Infratemporal Fossa Complicated with Orbital Apex Syndromes

BACKGROUND

The infratemporal fossa poses a great challenge to surgeons due to its complex anatomy and communications to many surrounding areas. The disorders that arise from this area can be infections and neoplasms. They can cause varieties of complications due to the extension of the pathologies and compression effect to the other adjacent structures. Inflammatory pseudotumor of the infratemporal fossa is one of the rare disorders of the head and neck.

CASE PRESENTATION

We report a patient with a pseudotumor of infratemporal fossa that extends to the orbital area and cavernous sinus, causing orbital apex syndromes. The diagnostic imaging, different surgical approaches of the biopsy and methods of treatment of this case are discussed.

DISCUSSION AND CONCLUSION

Radiological imaging and immunohistopathology are essential in establishing the diagnosis and determine the complications. The surgeons must well understand the characteristics and the impact of the disorders on the adjacent structure and give prompt decision to provide definitive treatments.

Knowledge, Attitude, and Practice of Intranasal Corticosteroid in Allergic Rhinitis Patients: Development of a New Questionnaire

Objectives: The knowledge gap and attitude of allergic rhinitis (AR) patients using intranasal corticosteroid (INCS) led to the poor outcome of their disease. We aimed to develop and validate a new questionnaire to assess the knowledge, attitude, and practice (KAP) of AR patients that can be used to assess and understand the factors affecting compliance of INCS. Methods: The questionnaire comprised development and validation stages. A self-administered questionnaire was developed after a comprehensive literature review. It was subjected to content and face validity before a revised final version was drafted. Exploratory factor analysis was used to assess the validity of the questionnaire. Cronbach’s alpha was used to verify internal consistency. Results: The development phase resulted in a questionnaire consisting of 14 items. Explanatory factor analysis revealed four factors associated with KAP. The four factors were extracted, and 12 items were kept. The factors were attitude domain with four items (factor 1), practice domain with four items (factor 2), and knowledge domain with four items (factor 3 has two items, and factor 4 has two items). The Cronbach’s alpha of the four factors ranged from 0.614 to 0.809. The final questionnaire consists of 3 domains with 12 items (the knowledge domain with four questions; the attitude domain with four questions; the practice domain with four questions) and was valid and reliable. Conclusions: The newly developed questionnaire has adequate validity and reliability. It is a useful tool to improve the treatment of AR patients by understanding the factors affecting their compliance.

Unilateral Tubarial Oncocytic Papillary Cystadenoma Presenting with Epistaxis

Oncocytic papillary cystadenoma (OPC) is a relatively rare benign tumor of the salivary glands, frequently seen in minor salivary glands, and occasionally in major salivary glands, such as the parotid gland. Patients only become symptomatic upon progression of the swelling, causing obstructive symptoms depending on its location. To our knowledge, there are no reports of presentation with bleeding tumor. Herein, we report a case of an OPC of the right torus tubarius in a 54-year-old man who presented with recurrent epistaxis.

Pediatric Sinonasal Rhabdomyosarcoma Presented as Squint: A Case Report and Literature Review

Rhabdomyosarcoma (RMS) is the most common soft-tissue tumor in children, frequently affecting the nose, nasopharynx, and paranasal sinuses. RMS of this sinonasal region manifests with non-specific nasal symptoms of allergic rhinitis, sinusitis, or upper airway infection. Associated ocular symptoms are rare. We describe a young girl who presented with acute onset squint secondary to sinonasal RMS. Imaging showed an aggressive sinonasal tumor with oropharyngeal, intraorbital, and intracranial extension. Histopathological findings were consistent with a diagnosis of rhabdomyosarcoma, embryonal type. The patient deteriorated rapidly due to disease complications. We provide a literature review of pediatric sinonasal RMS with various manifestations.

Design of InnoPrimers-Duplex Real-Time PCR for Detection and Treatment Response Prediction of EBV-Associated Nasopharyngeal Carcinoma Circulating Genetic Biomarker

Nasopharyngeal carcinoma (NPC) is an epithelial tumor with high prevalence in southern China and Southeast Asia. NPC is well associated with the Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) 30 bp deletion by having its vital role in increased tumorigenicity and decreased immune recognition of EBV-related tumors. This study developed an InnoPrimers-duplex qPCR for detection of NPC blood circulating LMP1 30 bp deletion genetic biomarker for early diagnosis and treatment response prediction of NPC patients. The analytical and diagnostic evaluation and treatment response prediction were conducted using NPC patients’ whole blood (WB) and tissue samples and non-NPC cancer patients and healthy individuals’ WB samples. The assay was able to detect as low as 20 ag DNA per reaction (equivalent to 173 copies) with high specificity against broad reference microorganisms and archive NPC biopsy tissue and FNA samples. The diagnostic sensitivity and specificity were 83.3% and 100%, respectively. The 30 bp deletion genetic biomarker was found to be a good prognostic biomarker associated with overall clinical outcome of NPC WHO type III patients. This sensitive and specific assay can help clinicians in early diagnosis and treatment response prediction of NPC patients, which will enhance treatment outcome and lead to better life-saving.

Transoral Surgical Excision Of A Parapharyngeal Space Tumour: Case Report And Literature Review

BACKGROUND

The parapharyngeal tumour is a rare case of head and neck tumour. Benign and malignant tumours can arise from any of the structures contained within the parapharyngeal space. Pleomorphic adenoma is the most typical salivary gland tumour that is found in this space and surgical resection is the main treatment for this tumour. Since the modern era of the medicine, different kinds of diagnostic imaging and surgical approaches have been introduced to evaluate this tumour.

CASE PRESENTATION

We present a case report of a parapharyngeal space mass that was found to be pleomorphic adenoma of minor salivary gland, their clinical presentation, radiological imaging and literature review of the transoral surgical approaches for parapharyngeal tumour.

DISCUSSION AND CONCLUSION

The transoral approach remains one of the classical and effective methods for the resection of the benign prestyloid parapharyngeal tumour. The surgeons need to have a good knowledge of diagnostic imaging and surgical techniques to determine which surgical procedure is the best for the patients in order to eradicate the diseases and minimize the complications ultimately.

Challenges in conducting post graduate otorhinolarygology-head and neck surgery specialty examination in the time of pandemic

No abstract provided.

Efficacy and safety of intralymphatic immunotherapy in allergic rhinitis: A systematic review and meta-analysis

BACKGROUND

Intralymphatic immunotherapy (ILIT) is a potential treatment option for allergic rhinitis (AR). We aimed to determine the efficacy (primary outcomes) and safety (secondary outcomes) of ILIT in treating patients with AR.

METHODS

An electronic literature search was performed using MEDLINE and Cochrane Central Register of Controlled Trials CENTRAL (from their inception to December 2020). A random-effects model was used to estimate the pooled prevalence with 95% confidence intervals. This study is registered with PROSPERO (CRD42019126271).

RESULTS

We retrieved a total of 285 articles, of which 11 satisfied our inclusion criteria. There were 452 participants with age ranged from 15 to 58 years old. Intralymphatic immunotherapy was given in three doses with intervals of four weeks between doses in 10 trials. One trial gave three and six doses with an interval of two weeks. Both primary and secondary outcomes showed no difference between ILIT and placebo for all trials. There was no difference in the combined symptoms and medication score (SMD -0.51, 95% CI -1.31 to 0.28), symptoms score (SMD -0.27, 95% CI -0.91 to 0.38), medication score (SMD -6.56, 95% CI -21.48 to 8.37), rescue medication (RR 12.32, 95% CI 0.72-211.79) and the overall improvement score (MD -0.07, 95% CI -2.28 to 2.14) between ILIT and placebo. No major adverse events noted.

CONCLUSIONS

Intralymphatic immunotherapy possibly has a role in the treatment of AR patients. This review found it is safe but not effective, which could be contributed by the high variation amongst the trials. Future trials should involve larger numbers of participants and report standardized administration of ILIT and outcome measures.

Clinical symptoms of chronic rhinosinusitis with nasal polyps (eosinophilic and non-eosinophilic) are related to sinus computed tomography but not to endoscopic findings

BACKGROUND

In the clinical assessment of chronic rhinosinusitis with nasal polyps (CRSwNP), evaluation of symptoms, nasoendoscopy findings and sinus computed tomography (CT) scan staging is employed in the management plan. Although prior studies have been done to assess the correlation of the three modalities in CRSwNP, such evaluation in patients with eosinophilic and non-eosinophilic types of CRSwNP requires further investigation. The aim of this study was to correlate the sinus CT scan staging to symptom and endoscopic scores in both types of CRSwNP.

MATERIAL AND METHOD

Patients with CRSwNP were classified into 2 types, eosinophilic and non-eosinophilic. Both types were assessed by Sino-Nasal Outcome Test 22 (SNOT-22) symptom score, nasal endoscopy Lund Kennedy grading (LK) score and sinus CT Lund Mackay (LM) staging score. All three modalities were correlated.

RESULTS

Forty-four patients were recruited for this study. There was significant correlation between sinus CT and symptom scores in the eosinophilic (r=.51, p=.031) and the non-eosinophilic (r=.76, p<.001) types. There was no significant correlation between symptom and nasoendoscopic scores in the eosinophilic (r=.12, p=.641) and the non-eosinophilic (r=.22, p=.276) types. There was also no significant correlation between sinus CT and nasoendoscopic scores in the eosinophilic (r=.20, p=.418) and the non-eosinophilic (r=.14, p=.508) types.

CONCLUSIONS

Sinus CT staging correlates well with the symptom score for both the eosinophilic and the non-eosinophilic types of CRSwNP. The good correlation suggests both modalities are a reliable guide for their evaluation and management planning.

The Association Between Obstructive Sleep Apnea and Allergic Rhinitis: Current Literature Review

:

Sleep-disordered breathing (SDB) is now a significant health problem in today's culture. It ranges from a spectrum of abnormal conditions during sleep from the primary snorer to mild, moderate, or severe obstructive sleep apnea (OSA). SDB also comprises other conditions, such as sleep-related hypoventilation, sleep-related hypoxemia, and central sleep apnea syndromes.

:

One of the components of the pathophysiology of OSA that remain unclear is the association of allergic rhinitis (AR) in the evolution of OSA. Several studies relate the co-existence of OSA and AR in the common clinical practice, but its correlation was not clear. This review article aimed to review the pathophysiological relationship between OSA and AR in terms of the role of chemical mediators and the effect of AR treatment in support of OSA.

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The symptoms of AR further accelerate the clinical progression to OSA development. Inflammatory mediators such as histamine, cysteinyl leukotrienes, and interleukins are found at a high level in AR, which can aggravate AR symptoms such as nasal obstruction, rhinorrhea, and itchiness, which can then lead to sleep disruption in OSA patients. In addition, OSA patients also have increased chemical mediators such as tumor necrosis factor, interleukin 6, and 1, which would activate the T helper 2 phenotypes that can aggravate AR symptoms. This vicious cycle can potentiate each other and worsen the condition. Few studies have shown that treatment of AR can improve OSA, especially the use of intranasal steroid and leukotriene receptor antagonists.

:

A detailed evaluation of rhinitis symptoms should be made for OSA patients so that they can benefit not only from the improvement of AR but also the good sleep quality.

Surgical Interventions for Inferior Turbinate Hypertrophy: A Comprehensive Review of Current Techniques and Technologies

Surgical treatment of the inferior turbinates is required for hypertrophic inferior turbinates refractory to medical treatments. The main goal of surgical reduction of the inferior turbinate is to relieve the obstruction while preserving the function of the turbinate. There have been a variety of surgical techniques described and performed over the years. Irrespective of the techniques and technologies employed, the surgical techniques are classified into two types, the mucosal-sparing and non-mucosal-sparing, based on the preservation of the medial mucosa of the inferior turbinates. Although effective in relieving nasal block, the non-mucosal-sparing techniques have been associated with postoperative complications such as excessive bleeding, crusting, pain, and prolonged recovery period. These complications are avoided in the mucosal-sparing approach, rendering it the preferred option. Although widely performed, there is significant confusion and detachment between current practices and their basic objectives. This conflict may be explained by misperception over the myriad of available surgical techniques and misconception of the rationale in performing the turbinate reduction. A comprehensive review of each surgical intervention is crucial to better define each procedure and improve understanding of the principle and mechanism involved.