Aetiological profile of paediatric stridor in a Malaysian tertiary hospital

BACKGROUND

Conditions causing stridor in paediatric patients can range from minor illnesses to life-threatening disorders. Proper evaluation and correct diagnosis are essential for timely intervention. The objective of this study was to determine the aetiological profiles and the management of paediatric patients with stridor referred to the Otorhinolaryngology Department of Hospital Serdang.

METHODS

Medical records of all paediatric patients presenting with symptom of stridor from January 2010 to February 2015 were reviewed retrospectively. The patients' demographic data, clinical notes, laryngoscope findings, diagnosis and management were retrieved and analysed.

RESULTS

Out of the total 137 patients referred for noisy breathing, 121 patients had stridor and were included in this study. There were 73 males and 48 females-most were of Malay ethnicity (77.7%). The age of presentation ranged from newborn to 10 years, with a mean of 4.9 months. Eighteen patients (14.9%) had associated congenital pathologies. The majority were congenital causes (90.9%), in which laryngomalacia was the commonest (78.5%), followed by subglottic stenosis (5.0%), vallecular cyst (2.5%) and congenital vocal fold paralysis (2.5%). Twelve patients (9.9%) had synchronous airway lesion. The majority of the patients were managed conservatively. Thirty-one patients (25.6%) required surgical intervention, of which only one needed tracheostomy.

CONCLUSION

Laryngomalacia was the commonest cause of stridor among paediatric patients. A synchronous airway lesion should be considered if the child has persistent or severe symptoms. The majority of the patients were managed conservatively.

An unexpected lesion in cerebellopontine angle: hemangiopericytoma

hemangiopericytoma (hPC) is a rare tumor by definition and intracranial hPC makes up to less than one percent of all the intracranial tumors. It is a dural base tumor and its clinical features and radiological findings are similar to meningiomas. however, cerebellopontine angle hemangipericytoma had only been reported twice and would almost always be misdiagnosed. definite diagnosis is important, as the treatment of hPC is different from meningiomas and acoustic neuromas. we report a case of a young female who presented with atypical symptoms of left cerebellopontine angle mass. A literature review of the nature of the disease, radiological findings, immunohistochemical features and treatment options of the tumor are described.

Partial Cricotracheal Resection (PCTR), a Rewarding Outcome for Paediatric Subglottic Stenosis: An Early Experience

This is a retrospective study examining the outcome of paediatric patients with subglottic stenosis who underwent partial cricotracheal resection (PCTR) as a primary open procedure from 2004 to 2012. There were 5 patients identified aged from 3 to 18 years old. All the subglottic stenosis were acquired type. All of them were secondary to prolonged intubation. Three patients were classified as Myer-Cotton grade III and the other two were Myer-Cotton grade IV. Two of the patients had concomitant bilateral vocal cord immobility. All patients underwent two staged PCTR . All patients underwent two staged PCTR, and one patient underwent posterior cordectomy apart from partial CTR at different setting. All patients were successfully decannulated at various durations postoperatively. Although this is an early experience in our institution, PCTR has shown to be effective and safe procedure in patients with subglottic stenosis especially those with Myer-Cotton grade III and IV.

The Prevalence of Sensorineural Hearing Loss in β-thalassaemia patient treated with Desferrioxamine

OBJECTIVE

This study aimed to evaluate the prevalence of sensorineural hearing loss (SNHL) in β-thalassaemia patients treated with Desferrioxamine (DFO) and determine the correlation of SNHL with average daily DFO dosage, serum ferritin level and Therapeutic index (T.I).

METHODS

This is a cross sectional descriptive study carried out for a period of 14 months and 54 patients were recruited. The recruited patients are transfusion dependant β- thalassaemia patient aged 3 years and above treated with DFO. An interview, clinical examination and hearing assessment, which included tympanogram, and Pure Tone Audiometry (PTA) or behaviour alaudiometry were performed. The data on age started on DFO, average daily DFO, duration of DFO intake, serum ferritin past 1 year and Therapeutic Index (T.I) were obtained from patients' case notes.

RESULTS

The prevalence of SNHL was 57.4% and majority has mild hearing loss (93.6%). Fourteen patients (25.9%) have bilateral ear involvement and as many as 17 patients (31.5%) have SNHL in either ear. A total of 23 patients (42.6%) have normal hearing level. Although the prevalence of SNHL was 57.4%, only a small percentage of the patient noticed and complained of hearing loss (11.1%). There is no association between age started on DFO, average daily DFO and duration of DFO intake with normal hearing group and those patients with SNHL. Positive correlation was seen between average daily DFO with 2000 and 4000Hz on PTA in the left ear and between serum ferritin level past 1 year with 4000 and 8000Hz in the right ear and 8000Hz in the left ear. No significant correlation was seen between T.I on PTA.

CONCLUSION

The prevalence of SNHL from hearing assessment is high in β-thalassaemia patients in this study. However, it is manifested clinically in a smaller percentage. We suggest a baseline hearing assessment should be carried on all β-thalassaemia patients prior to DFO chelation therapy.

Surgical outcome of bone anchored hearing aid (baha) implant surgery: a 10 years experience

Bone anchored hearing aid (Baha) implant is an option for patient with canal atresia, single sided deafness(SSD) and chronically discharging ears despite treatments. This retrospective study was conducted from 2001 to 2011 to evaluate the surgical outcome of Baha implant surgery. Thirty-three patients were identified during this study period. Their age at implantation ranged from 5 to 40 years. Of 33 patients, 29 (87.9 %) patients had bilateral microtia and canal atresia, 3 (9.1 %) patients had unilateral microtia and canal atresia and 1 (3.0 %) patients have SSD following labyrinthitis. One patient (3.2 %) had major complication which is lost of implant due to failure of osseointegration. Soft tissue reactions were seen 7 patients (21.1 %). Of these 7 patients, 4 patients required 3-4 procedures as day care operation for excision of the skin overgrowth surrounding the abutment. Recurrent antibiotic treatment was required in 3 patients (9.7 %). None of our patient had history of intraoperative or peri-operative complication following Baha surgery. The commonest complications are local infection and inflammation at the implant site. None of our patient had history of intraoperative or peri-operative complication following Baha implant surgery.

Hidden foreign body in an unexplained asthma

Foreign body aspiration (FBA) is a common condition with potential to cause significant morbidity and mortality. In children, highest incidence is within the first 3 years of life. Without witnessed aspiration or acute symptoms such as choking, coughing or respiratory distress, it may go unnoticed as clinical presentation and radiological investigations generally have low diagnostic value. Delay in diagnosis increases the risk of developing severe complications. Unexplained recurring or persistent lung pathologies in this age group should raise suspicion of FBA, and early bronchoscopy is warranted for confirmation of diagnosis. We report a case of FBA in a 2-year-old boy whom had been symptomatic for 3 months and was treated as bronchial asthma prior to diagnosis of foreign body in the left bronchus. DOI: http://dx.doi.org/10.3329/bjo.v18i2.12017 Bangladesh J Otorhinolaryngol 2012; 18(2): 200-202

Primary clear cell carcinoma of minor salivary gland of the soft palate: a case report

Clear cells can be found in numerous salivary and non-salivary tumors in the head and neck region, including metastatic lesions. They are rare low-grade tumors accounting for less than 1% of all salivary gland tumors and occur almost exclusively in the intra-oral minor salivary glands. Hyalinizing clear cell carcinoma (HCCC) is an extremely rare and recently described neoplasm predominantly affecting the oral cavity. Histologically, it is characterized by nests of glycogen-rich monomorphic clear cells within a hyaline stroma. HCCC often follows an indolent course with a limited metastatic potential. It is therefore important to differentiate this entity from other more aggressive clear cell tumors including metastatic tumors such as renal cell carcinoma. We hereby report a case of HCCC localized in minor salivary glands specifically in soft palate for its rarity, as well as to discuss the role of immunohistochemical stains, essential for its definitive diagnosis.

Preauricular pilomatrixoma in a 3 year-old girl: A case study

Objectives: To report a case of preauricular pilomatrixoma in a 3-year-old girl.Methods: Retrospective review on a case reportResults: A three-year-old girl presented with six month history of painless right pre-auricular swelling that was gradually increasing in size. The mass was small, soft, non tender with normal overlying skin. She underwent excisional biopsy of lesion and histopathological examination showed pilomatrixoma. She was well post operatively and no recurrence after 2 years of follow up.Conclusion: Pilomatrixoma is often misdiagnosed clinically as epidermoid cyst, sebaceous cyst, dermoid cyst, foreign body reaction, calcification in lymph node, fat necrosis, pyogenic granuloma, chalazion and keratoacanthoma, but a high index of suspicion and careful histological examination of its characteristic clinical feature can help clinicians to differentiate it from other tumors.   DOI: http://dx.doi.org/10.3329/bjo.v18i1.10426  Bangladesh J Otorhinolaryngol 2012; 18(1): 84-86

Stem cell genes are poorly expressed in chondrocytes from microtic cartilage

OBJECTIVES

This study was aimed to see the difference between chondrocytes from normal cartilage compared to chondrocytes from microtic cartilage. Specific attentions were to characterize the growth of chondrocytes in terms of cell morphology, growth profile and RT-PCR analysis.

STUDY DESIGN

Laboratory experiment using auricular chondrocytes.

METHODS

Chondrocytes were isolated from normal and microtic human auricular cartilage after ear reconstructive surgeries carried out at the Universiti Kebangsaan Malaysia Medical Centre. Chondrocytes were cultured in vitro and subcultured until passage 4. Upon confluency, cultured chondrocytes at each passage (P1, P2, P3 and P4) were harvested and subjected to growth profile and gene expression analyses. Comparison was made between the microtic and normal chondrocytes.

RESULTS

For growth profile analysis cell viability did not show significant differences between both samples. There are no significance differences between both samples in terms of its growth rate, except in passage 1 where microtic chondrocytes were significant lower in their growth rate. Population doubling time and total number of cell doubling of all samples also did not show any significant differences. Gene expression is measured using Real Time-Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). There is no significant differences in the expression of collagen type I, collagen type II, collagen type X, aggrecan core protein, elastin and sox9 genes in both samples. There are significant lower in the expression of sox2, nestin, BST-1 and OCT-4 gene in microtic chondrocytes compared to the normal chondrocytes. Stem cells markers are included in this study as stemness in cells may imply a greater proliferative potential and plasticity in vitro.

CONCLUSION

Chondrocytes from microtic samples have the same properties as chondrocytes from normal samples and hold promises to be used as a starting material in the reconstruction of the external ear in future clinical application. The reduction in sox2, nestin, BST-1 and OCT-4 gene expression in microtic samples could be the possible cause of the arrested development of the external ear.

Congenital cholesteatoma: delayed diagnosis and its consequences

This is a retrospective review of congenital cholesteatoma cases that were managed surgically. There were 5 cases. The age of presentation ranged from 5 to 18 year old. Three patients presented with complication of the disease. Three patients had intact tympanic membrane, two had perforation at the anterior superior quadrant. All patients had cholesteatoma medial to tympanic membrane. Four cases had extensive ossicular erosion with preoperative hearing worse than 40 dB. Four cases underwent canal wall down mastoid surgery and one underwent canal wall up surgery. One patient had recurrence which required revision surgery. In conclusion, congenital cholesteatoma presented late due to the silent nature of disease in its early stage. Extensive disease, ossicular destruction with risk of complication at presentation were marked in our study. Hence, more aggressive surgical intervention is recommended in the management of congenital cholesteatoma.

A ten year retrospective review of orbital complications secondary to acute sinusitis in children

Acute sinusitis is most often a mild self-limiting disease. However, it may progress into severe and life threatening complications. One of the commonest being orbital complication of which visual loss is a direct consequence. In this 10 year retrospective study, the nature of orbital complication, clinical presentation and treatment modalities and outcome seen in children with acute sinusitis in a tertiary referral institute were reviewed. Of six patients, there was a case of preseptal cellulitis, 4 cases of subperiosteal abscess and one case of orbital abscess. Periorbital swelling was a common presenting feature. In 5 cases this was associated with proptosis with one case of impending optic nerve compression. The value of computed tomography and opthalmological examination as a component in the management plan is highlighted. All patients were treated with intravenous antibiotics but evidence of abscess collection warranted urgent surgical drainage in 5 patients, 3 being endoscopic drainage while external approach was done for the remaining 2 patients. Thus a child exhibiting orbital complication of acute sinusitis, prompt diagnosis and treatment is essential in obtaining the best outcome for the child.

Retrospective review of surgical management of foreign body ingestion

Endoscopic examination and removal of foreign body under general anaesthesia are recommended for persistent symptomatic patient with or without significant findings on radiological examination. This report evaluates the management outcome of surgical removal of foreign body ingestion in upper gastrointestinal tract. A total of 70 cases with full documentation were reviewed retrospectively from June 1998 until December 2007. There were 32 male and 38 female with age range from 6 months to 87 years old (mean: 36.9 years). Sixty five patients (93%) were adults and 15 (7%) were below 13 years. Fish bones were the most common foreign body found (44.3%). Radiologically, foreign bodies were highly suspicious in 51 cases (76.1%). Intraoperatively, thirty six cases (70.6%) were positive. From 16 cases (23.9%) with normal radiograph, 10 cases (62.5%) were found to have foreign bodies. Therefore the plain radiograph is helpful, but clinical presentation is more reliable to determine surgical removal under general anaesthesia.

Hearing rehabilitation in congenital canal atresia

INTRODUCTION

The purpose of this study was to review the results of our patients with congenital canal atresia after implantation of bone-anchored hearing aids (BAHA). The occurrence of complications was also reviewed.

METHODS

This was a retrospective analysis of the first 16 patients who had BAHA implantation at Universiti Kebangsaan Malaysia Medical Centre, Malaysia. Audiometric assessment was done preoperatively and postoperatively for each patient using the standard procedure. The surgical procedure was described and its complications discussed.

RESULTS

The 16 patients consisted of 11 male and five female patients. Their mean age was 8.9 years at the time of the surgery. The main indication was bilateral canal atresia. 11 patients had implantation of BAHA performed in two stages, while the other five patients had it as a single-staged procedure. The complications that occurred were failure of osseointegration (one patient), granulation tissue overgrowth into the abutment (two patients) and cellulitis surrounding the abutment (three patients). The average preoperative unaided air conduction threshold was 64.9 dB and the average postoperative aided hearing threshold was 29.7 dB. The overall mean functional gain was 35.2 dB.

CONCLUSION

BAHA has many advantages over the conventional hearing aid in the form of cosmesis, discomfort and hearing gain. It is a reliable hearing rehabilitation tool with good predictable hearing outcome in patients with bilateral canal atresia, especially those unsuitable for canalplasty. Despite its higher cost and the need for surgical implantation, its use is justifiable in properly selected patients.

Growth kinetic study on normal and microtic chondrocytes of human auricular cartilage

Chondrocytes were isolated from normal and microtic human auricular cartilage after ear surgery carried out at Universiti Kebangsaan Malaysia Medical Centre. Chondrocytes were cultured and expanded until passage 4. After reached confluence, cultured chondrocytes at each passage (P1, P2, P3 and P4) were harvested and assigned for growth profile analysis. There was no significant difference in cell viability between both normal and microtic samples (p = 0.84). Both samples showed no significant differences for growth profile parameters in terms of growth rate, population doubling time and total number of cell doubling, except in passage 1, where there is significant difference in cell growth rate (p = 0.004). This preliminary data has indicated that chondrocytes from microtic cartilage has the potential to be used in the reconstruction of human pinna in the future.

Internal auditory canal stenosis in congenital sensorineural hearing loss

OBJECTIVE

Sensorineural hearing loss (SNHL) due to internal auditory canal (IAC) stenosis with hypoplasia of the cochleovestibular nerve is a rare disorder. The diagnosis of the IAC stenosis requires both high resolution computed tomography scan (HRCT) and magnetic resonance imaging (MRI).

METHODS

A retrospective review over 6 years in an academic tertiary referral center was performed.

RESULTS

Six patients with congenital SNHL were diagnosed with congenital IAC stenosis. Four had unilateral and two had bilateral IAC stenosis after imaging. MRI showed hypoplastic vestibulocochlear nerve in all cases.

CONCLUSIONS

This paper highlights the importance of imaging in diagnosing IAC stenosis and detecting the presence of cochleovestibular nerve in cases of congenital SNHL.

Parotid abscess: a five-year review – clinical presentation, diagnosis and management

Parotid abscess is an uncommon complication of suppurative infection of the parotid gland parenchyma, commonly bacterial or viral. Ductal ectasis, primary parenchymal involvement, or infection of the intraparotid or periparotid lymph nodes can result in abscess formation. Parotid abscess may arise from ductal ectasis, primary parenchymal involvement, or infection of the subcapsular lymph nodes. The operative records for all the patients who underwent surgeries in the Department of Otorhinolaryngology, Head and Neck Surgery of the National University Hospital, Kuala Lumpur, Malaysia between January 2001 and December 2005 were retrospectively reviewed. Our case series comprises 15 patients, with 10 males and five females with a median age at presentation of 51 years old. Diabetes mellitus is a significant comorbid factor, with six patients being diabetics. Among the diabetics, two patients presented with facial nerve palsy and one of them also died due to overwhelming septicaemia. Here, we discuss the presenting symptoms, predisposing factors, investigations, microbiology and complications of this condition.

Paediatric tracheostomy in Hospital University Kebangsaan Malaysia - a changing trend

Indication for pediatric tracheostomy has changed. Upper airway obstruction secondary to infectious disorders is no longer the commonest indication. The aim of this study was to establish data on indications, outcome and complications of pediatric tracheostomy. A retrospective analysis of pediatric tracheostomies carried out between March 2002 to March 2004 was done. Eighteen patients were identified. The commonest indication was prolonged ventilation (94.5%) followed by pulmonary toilet (5.5%). None was performed for upper airway obstruction. Postoperative complications were encountered in six patients (33.3%), the commonest being accidental decannulation notably in children less than six years of age. Twelve patients (66.6%) were successfully decannulated. The mortality rate was 16.6%. All death were non tracheostomy related. The commonest indication for tracheostomy was prolonged ventilation and tracheostomy in children is relatively safe despite complications.

Endoscopic repair of spontaneous cerebro-spinal fluid rhinorrhoea: a report of 3 cases

Three cases of spontaneous Cerebrospinal Fluid (CSF) rhinorrhea were managed at the National University Hospital, Kuala Lumpur. Case 1 had bilateral leak secondary to empty sella syndrome and the rest two cases had unilateral leak. Four transnasal endoscopic approaches were performed on these three cases since March 1999. The role of intrathecal Sodium Fluorescein is highlighted in localising the CSF fistula. Case 3 required postoperative lumbar drain as an adjunct. No recurrent leak was noted on post operative follow up in Case 2 and 3 ranging from nine to thirty two months. A recurrent left leak at six months was noted in Case 1 which could likely be due to her sudden bout of cough attacks and patient refused further surgical intervention.

Stability in Gilpin and Ayala's models of competition

Simple and effective conditions for global stability in a class of models for m competing species are given. A numerical method is used to establish a large finite region of attraction for the feasible equilibrium in Gilpin and Ayala's model of two competing Drosophila populations.

Stability in a class of discrete time models of interacting populations

Effective Lyapunov and Lyapunov-like functions for a class of discrete time models of interacting populations are presented. These functions are constructed on the biologically meaningful principle that a viable population must absorb energy from external sources when its density is low and it must dissipate energy to the environment when its density is high. These functions can be used to establish that a discrete time model is globally stable or that its solutions are ultimately confined to an acceptable region of the state space. The latter is especially interesting when the model has chaotic solutions. These methods are applied to a single species model and a model of competition between two species.