A Rare Case of Complicated Sinonasal Meliodosis Mimicking Sinonasal Lymphoproliferative Disease

Unilateral nasal obstruction with purulent nasal discharge is one of the presentations for sinonasal melioidosis. However, it may mimic nasal NK/T cell lymphoma. Both causing tissue destruction involving nasal septum, lateral nasal wall and palate. Here, we report a case of disseminated melioidosis involving sinonasal mimicking nasal lymphoma in a 32-year-old immunocompetent lady. She presented with prolonged fever, unilateral nasal blockage, painful facial swelling and knee pain. Clinical findings revealed extensive necrotic tissue and crusting involving right lateral wall of nasal cavity. Tissue and blood culture and sensitivity (C + S) grew Burkholderia pseudomallei. Recovery was complete after surgery and antibiotics.

A Rare Case and Literature Review of Endoscopic Endonasal

We report a rare case of localized anterior clinoid mucocele (ACM) with acute visual loss and a literature review of the endoscopic endonasal surgery. We advocate that endoscopic endonasal approach is the best choice. To our knowledge there a limited report on localized ACM that treated via endoscopic endonasal approach.

Challenges in Managing Intractable Epistaxis in a Post-nasal Surgery and Radiated Cancer Patient: A Case Report and Literature Review

Recurrent epistaxis represents an alarming sign that may suggest a sinister aetiology, especially in patients with previous head and neck malignancy. The recognition of certain potentially life-threatening conditions, namely pseudoaneurysm or tumour recurrence, remains prudence to avoid disastrous repercussion. Nasal endoscopy has become an essential tool in otolaryngology. It can aid identify the underlying cause of epistasis and facilitate therapeutic management. On the other hand, radio imaging is highly sensitive in detecting vascular lesions, besides providing a pre-operative mapping if surgical intervention is planned. This paper reported a patient with sphenoidal sinus squamous cell carcinoma in remission presented with torrential epistaxis not relieved with nasal packing. Despite a repeated angiogram and magnetic resonance image, the identification of the source of bleeding remained futile, culminating in an examination under general anaesthesia. The diagnosis of carotid blowout syndrome was made intraoperatively, and the bleeding was temporarily secured with a muscular patch, preceded by the insertion of a vascular stent. The authors wish to highlight the importance of examination under general anaesthesia if radio imaging does not correlate to the clinical findings. Management options for carotid blowout should be tailored to the patients' medical conditions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03625-4.

Pharyngeal Lipoma-A Potentially Life Threatening Presentation

Pharyngeal lipoma of the upper aero-digestive system is extremely rare. It is typically benign, slow growing and symptoms would depend on its size and location. Surgical intervention is often needed especially for large tumour with impending airway obstruction. Here we present a case of potentially life threatening presentation of pharyngeal lipoma.

Temporal bone squamous cell carcinoma: A change in treatment

Temporal bone squamous cell carcinoma (TBSCC) is a rare head and neck malignancy with the incidence 0.8 -1.0 cases in 1 million population. We are reporting a case series on the TBSCC cases that were operated on at Sarawak General Hospital, Malaysia. Ten patients were identified and collected with the presentation and type of surgery performed. It has been challenging for us to manage with recorded 2 years surviving in 6 out of 10 patients operated within this period. An adequate management with proper surgical resection of tumour and radiotherapy can extend the life expectancy for TBSCC patients.

A caroticocavernous fistula without vascular injury following endoscopic transsphenoidal excision of a tuberculum sellae meningioma-A case report

Caroticocavernous fistulae can occur following transsphenoidal surgery even without evidence of carotid artery injury. A role of vascularized flap reconstruction may be contributory.

Cabbage and fermented vegetables: From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID‐19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS‐CoV‐2 binds to its receptor, the angiotensin‐converting enzyme 2 (ACE2). As a result of SARS‐CoV‐2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT₁R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID‐19. The nuclear factor (erythroid‐derived 2)‐like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT₁R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof‐of‐concept of dietary manipulations that may enhance Nrf2‐associated antioxidant effects, helpful in mitigating COVID‐19 severity.

Spontaneous orbital haematoma in a scurvy child: A forgotten diagnosis

Spontaneous unilateral orbital haematoma in children is not common and very rarely caused by scurvy. Scurvy is a clinical syndrome with a spectrum of clinical manifestations due to severe prolonged vitamin C deficiency leading to impairment of collagen synthesis over skin, bone, teeth and blood vessels. This paper presents a unique case of a 7- year-old girl with learning difficulty who presented with spontaneous right proptosis due to scurvy. Imaging studies suggestive of intra- orbital extraconal haemorrhage. The child was treated with a higher than recommended dose of vitamin C initially in emergency situation. She responded well and discharged without complication. Spontaneous orbital haematoma due to scurvy is very rare with less than 10 cases published in literature. The present case should raise the awareness regarding this forgotten disease and importance of balance nutrition amongst children.

Unilateral pulmonary vein atresia presenting with recurrent haemoptysis in a child: a case report

BACKGROUND

Haemoptysis is an uncommon presenting symptom in children and is usually caused by acute lower respiratory tract infection or foreign body aspiration. We report a rare case of right unilateral pulmonary vein atresia (PVA) as the underlying aetiology of recurrent haemoptysis in a child.

CASE PRESENTATION

A 4 years old girl presented with history of recurrent haemoptysis. Bronchoscopic evaluation excluded a foreign body aspiration but revealed right bronchial mucosal hyperaemia and varices. Diagnosis of right unilateral PVA was suspected on transthoracic echocardiography which demonstrated hypoplastic right pulmonary artery and non-visualization of right pulmonary veins. Final diagnosis was confirmed on cardiac CT angiography. A conservative treatment approach was opted with consideration for pneumonectomy in future when she is older.

CONCLUSION

Rarer causes should be considered when investigating for recurrent haemoptysis in children. Bronchoscopy and cardiac imaging are useful tools to establish the diagnosis of unilateral PVA in our case.

Laryngeal Leiomyosarcoma: A Rare Case

Laryngeal leiomyosarcoma is a rare smooth muscle malignancy of the head and neck region. Diagnosis is based on immunohistochemistry. Here we present a case of laryngeal leiomyosarcoma that was diagnosed and treated in our center, focusing on the clinical features, histological diagnosis and management of this rare disease.

Radiological Study of the Ethmoidal Arteries in the Nasal Cavity and Its Pertinence to the Endoscopic Surgeon

We studied the ethmoidal arteries using preexisting computer tomography of the paranasal sinuses (CT PNS) and statistically scrutinized data obtained between genders. A descriptive study from 77 CT PNS dated January 2016-December 2016 were collected and reviewed by two radiologists. A total of 54 (108 sides) CT PNS were studied of patients aged 18-77 years. 37 are male, 17 are female; with Bumiputera Sarawak predominance of 25 patients, 12 Malays, 16 Chinese and one Indian. Rate of identification are as follows: anterior ethmoidal artery (AEA)-100%, middle ethmoidal artery (MEA)-30%, posterior ethmoidal artery (PEA)-86%. The average distance from AEA-MEA is 8.1 ± 1.52 mm, MEA-PEA is 5.5 ± 1.29 mm and AEA-PEA is 12.9 ± 1.27 mm. The mean distance from PEA-the anterior wall of sphenoid is 7.7 ± 3.96 mm, and PEA-optic canal is 8.5 ± 3.1 mm with no statistical difference when compared between gender. AEA frequently presented with a long mesentery 57.4%, while 87.1% of PEA was hidden in a bony canal. The vertical distance of the AEA-skull base ranges from 0 to 12.5 mm whilst PEA-skull base is 0-4.7 mm. There is no statistical difference in distances of AEA, MEA nor PEA to skull base when analyzed between genders; t(82) = 1.663, p > 0.05, t(32) = 0.403, p > 0.05 and t(75) = 1.333, p > 0.05 respectively. We newly discovered, that 50% of MEA is hidden in a bony canal, and its distance to skull base ranged 0-5.3 mm. MEA and PEA less commonly have a short or long mesentery. Knowledge on the ethmoidal arteries especially in our unstudied population of diverse ethnicity, gains to assist surgeons worldwide, when embarking in endoscopic transnasal surgeries.

Using Patient Profiles To Guide The Choice Of Antihistamines In The Primary Care Setting In Malaysia: Expert Consensus And Recommendations

H1-antihistamines are recognized to be effective for conditions such as allergic rhinitis and chronic spontaneous urticaria. However, management of such conditions in the real-world primary care setting may be challenging due to diverse patient-specific considerations, the wide range of antihistamines available, choice of other treatment modalities, and the complexity of interpreting specialist treatment algorithms. Despite regular updates to international guidelines, regional/national surveys of healthcare professionals show a clear gap between guidelines and real-world practice, particularly at the primary care level. This article thus presents the consensus opinion of experts from relevant specialties in Malaysia - allergology, pediatrics, otorhinolaryngology, and dermtology - on harmonizing the use and choice of antihistamines in primary care. Patient profiling is recommended as a tool to guide primary care practitioners in prescribing the appropriate antihistamine for each patient. Patient profiling is a three-step approach that involves 1) identifying the individual's needs; 2) reviewing patient-specific considerations; and 3) monitoring treatment response and referral to specialists in more severe or difficult-to-treat cases. Concurrently, guidelct 3ines should be reviewed and updated periodically to include recommendations that are easily actionable for primary care practitioners.

Dilemma in management of cervico-facial cystic hygroma

Cervico facial cystic hygroma and tongue lymphagioma is rare representative of spectrum of lymphatic malformations. Conservative management with sclerosants alone has proven to be successful. However, sudden enlargement of these cervico facial lymphangiomas leads to catastrophic airway obstruction leading to debility in feeding and speech. Therefore, surgery is indicated in such case to prevent such a catastrophic problem. We report here the case of a 3-yearold boy with cervico facial hygroma involving the tongue. We successfully treated him with a combination of surgery and OK432 injection.

Comparison of distortion product otoacoustic emission (DPOAE) and automated auditory brainstem response (AABR) for neonatal hearing screening in a hospital with high delivery rate

INTRODUCTION

Congenital hearing loss is one of the commonest congenital anomalies. Neonatal hearing screening aims to detect congenital hearing loss early and provide prompt intervention for better speech and language development. The two recommended methods for neonatal hearing screening are otoacoustic emission (OAE) and automated auditory brainstem response (AABR).

OBJECTIVE

To study the effectiveness of distortion product otoacoustic emission (DPOAE) and automated auditory brainstem response (AABR) as first screening tool among non-risk newborns in a hospital with high delivery rate.

METHOD

A total of 722 non-risk newborns (1444 ears) were screened with both DPOAE and AABR prior to discharge within one month. Babies who failed AABR were rescreened with AABR ± diagnostic auditory brainstem response tests within one month of age.

RESULTS

The pass rate for AABR (67.9%) was higher than DPOAE (50.1%). Both DPOAE and AABR pass rates improved significantly with increasing age (p-value<0.001). The highest pass rate for both DPOAE and AABR were between the age of 36-48 h, 73.1% and 84.2% respectively. The mean testing time for AABR (13.54 min ± 7.47) was significantly longer than DPOAE (3.52 min ± 1.87), with a p-value of <0.001.

CONCLUSIONS

OAE test is faster and easier than AABR, but with higher false positive rate. The most ideal hearing screening protocol should be tailored according to different centre.

A new experience of auditory brainstem implantation in Malaysia

Auditory brainstem implantation (ABI) is the only solution to restore hearing when cochlear nerves are disrupted together with the pathologies where bilateral cochleae do not provide a suitable location for cochlear implantation. We reported first two successful auditory brainstem implantation cases in patients with neurofibromatosis Type II (NF2) with bilateral acoustic neuroma causing bilateral profound sensorineural hearing loss in Malaysia. A good candidate selection, dedicated surgeons and rehabilitation team as well as strong family support are the crucial factors in achieving the best possible surgical, audiological and speech outcomes.

A review of surgical and audiological outcomes of bonebridge at tertiary centres in Malaysia

OBJECTIVES

To investigate the surgical and audiological outcome of Bonebridge (BB) at tertiary centres in Malaysia.

STUDY DESIGN

Prospective, intra-subject repeated measurements of which each subject is his/her own control, from year 2012 to 2016 at two tertiary referral centres.

METHODS

Twenty patients with hearing loss who fulfilled criteria for BB and showed good response to bone conduction hearing aid trial were included. Implantations of BB were carried out under general anaesthesia with preoperative computed tomography (CT) planning. Complications were monitored up to six months postoperatively. Subjects' audiometric thresholds for air conduction, bone conduction and sound field at frequencies of 250Hz to 8kHz were assessed preoperatively and at six months postoperatively. Subjects' satisfaction was evaluated at 6 months post operatively with Hearing Device Satisfaction Scale (HDSS) questionnaire.

RESULTS

There was no major complication reported. Mean aided sound field thresholds showed significant improvement for more than 30dB from 500 to 4000kHz (p<0.05). There was no significant change in mean unaided air conduction and bone conduction thresholds pre and post operatively from 500 to 4000kHz, with a difference of less than 5dB (p>0.05). All the patients were very satisfied (>80%) with the implant, attributing to the promising functional outcome and acceptable cosmetic appearance.

CONCLUSIONS

BB implantation surgery is safe and is effective in restoring hearing deficits among patients aged five and above with conductive or mixed hearing loss and single-sided hearing loss.

Pilot study comparing steroid-impregnated and non-steroid-impregnated absorbable nasal dressing following endoscopic sinus surgery

INTRODUCTION

Endoscopic sinus surgery (ESS) is the mainstay for treatment of chronic rhinosinusitis versus maximal medical therapy. We propose a more economical option, by using steroid-impregnated Gelfoam instead of Nasopore post ESS, as it is less expensive and has showed effectiveness in preventing post-operative bleeding.

MATERIALS AND METHODS

A randomised, double-blinded, placebo-controlled trial was carried out in eight patients with chronic rhinosinusitis or nasal polyposis who were planned for bilateral endoscopic sinus surgery. A Peri-operative Sinus Endoscopy (POSE) Score and Lund-Kennedy Endoscopic Score (LKES) were recorded. The use of hydrocortisone-impregnated Gelfoam dressing versus normal saline-impregnated Gelfoam dressing were compared. Scores were repeated post-operatively at one week, three weeks and three months interval.

RESULTS

For LKES, at the end of three months, 50% of the patients had the same score difference, 37.5% had better results on the study side while 12.5% had better results on the control side. Meanwhile, for POSE Score, at the end of three months, 75% of the patients had better score difference on the study side while 12.5% had better results on the control side.

CONCLUSION

Gelfoam can be used as nasal packing material to deliver topical steroid after endoscopic sinus surgery. Steroid-impregnated nasal dressing after endoscopic sinus surgery may not provide better long-term outcome.

Cavernous sinus fungal infection: a rare case

Intracranial fungal infection of the cavernous sinus is a condition that usually affects immunocompromised individuals and is rarely seen in immunocompetent individuals. It is a potentially life threatening condition which requires prompt treatment. Here we present a case of an immunocompetent patient with a fungal infection of the cavernous sinus.

Cervical lipoblastoma: An uncommon presentation

Lipoblastoma is extremely rare and mainly occurs in children younger than 3 years old. It is predominantly found in the extremities and trunk. Head and neck region occurrences are rare; only 4 such cases involving patients who presented with stridor have been previously reported. We report the fifth case of lipoblastoma of the neck with stridor in a 9-year-old girl, which had gradually worsened over the previous year. Imaging showed a retrotracheal mass extending superiorly to the thyroid level and inferiorly to below the carina of the trachea. Total resection of the tumor was performed, and the histopathologic findings were consistent with lipoblastoma. Postoperatively, the patient was well with no complications.

Sinonasal angioleiomyoma

BACKGROUND

Angioleiomyoma of the nasal cavity is an extremely rare benign neoplasm. It usually occurs in the lower extremities. Up to date, only few cases of angioleiomyoma have been reported. First case of angioleiomyoma of nasal cavity was reported in 1966. We report a rare case of angioleiomyoma arising from the right maxillary sinus.

CASE REPORT

A 43-year-old lady presented with recurrent epistaxis and right nasal obstruction for two months duration. Clinical examination revealed a huge right nasal mass obstructing the right nasal cavity. The tumour was excised completely via endoscopic endonasal surgical approach. Histopathological examination confirmed the tumour is sinonasal angioleiomyoma. Postoperatively, she recovered well without any recurrence after a year of followup.

CONCLUSION

This tumour has an excellent prognosis and recurrence is extremely rare if excised completely.

Comparative analysis of the anterior transpetrosal approach with the endoscopic endonasal approach to the petroclival region

OBJECTIVE The endoscopic endonasal approach (EEA) offers direct access to midline skull base lesions, and the anterior transpetrosal approach (ATPA) stands out as a method for granting entry into the upper and middle clival areas. This study evaluated the feasibility of performing EEA for tumors located in the petroclival region in comparison with ATPA. METHODS On 8 embalmed cadaver heads, EEA to the petroclival region was performed utilizing a 4-mm endoscope with either 0° or 30° lenses, and an ATPA was performed under microscopic visualization. A comparison was executed based on measurements of 5 heads (10 sides). Case illustrations were utilized to demonstrate the advantages and disadvantages of EEA and ATPA when dealing with petroclival conditions. RESULTS Extradurally, EEA allows direct access to the medial petrous apex, which is limited by the petrous and paraclival internal carotid artery (ICA) segments laterally. The ATPA offers direct access to the petrous apex, which is blocked by the petrous ICA and abducens nerve inferiorly. Intradurally, the EEA allows a direct view of the areas medial to the cisternal segment of cranial nerve VI with limited lateral exposure. ATPA offers excellent access to the cistern between cranial nerves III and VIII. The quantitative analysis demonstrated that the EEA corridor could be expanded laterally with an angled drill up to 1.8 times wider than the bone window between both paraclival ICA segments. CONCLUSIONS The midline, horizontal line of the petrous ICA segment, paraclival ICA segment, and the abducens nerve are the main landmarks used to decide which approach to the petroclival region to select. The EEA is superior to the ATPA for accessing lesions medial or caudal to the abducens nerve, such as chordomas, chondrosarcomas, and midclival meningiomas. The ATPA is superior to lesions located posterior and/or lateral to the paraclival ICA segment and lesions with extension to the middle fossa and/or infratemporal fossa. The EEA and ATPA are complementary and can be used independently or in combination with each other in order to approach complex petroclival lesions.

Surgical outcomes in cystic vestibular schwannoma versus solid vestibular schwannoma

OBJECTIVE

To review the postoperative surgical outcomes of cystic vestibular schwannomas (CVSs), especially facial nerve outcomes, and compare these results with those from matched solid vestibular schwannomas (SVS) resected during the same period at a tertiary referral center.

STUDY DESIGN

Retrospective case series.

METHODS

One hundred thirty-one surgically managed patients with cystic vestibular schwannomas (CVSs) were age, sex, and tumor size matched to 131 surgically managed patients with solid vestibular schwannomas (SVSs). Demographics, tumor morphology, surgical approach, extent of resection, facial and nonfacial complications, and recurrence rates were compared between the 2 groups. Subtotal removal was defined as removal of at least 95% of the tumor.

RESULTS

The mean maximal tumor diameter was 2.8 cm for both groups. For CVS, gross total tumor resection (GTR) was achieved in 92 patients (70.2%), and subtotal tumor resection (STR) was achieved in 39 patients (29.8%). Postoperative facial nerve outcomes at 1-year follow-up were good (HB Grade I-III) in 116 (88.5%) of 131 CVS patients. Twenty-three patients developed nonfacial nerve-related complications (17.6%). For SVS, GTR was achieved in 102 patients (77.9%), and STR was achieved in 29 patients (22.1%). Postoperative facial nerve outcomes at 1-year follow-up were good (HB Grade I-III) in 118 (90.1%) of 131 SVS patients. Nonfacial nerve related complications occurred in 14 patients (10.7%). None of the differences in outcome between the 2 groups were statistically significant.

CONCLUSION

The difference in surgical outcomes is minimal between patients with CVS and those with SVS, not reaching statistical significance. We think, with judicious surgical management, similar outcomes can be achieved in cystic tumors and solid tumors.

Kimura's Disease: Diagnostic Challenge and Treatment Modalities

CASE REPORT

Five cases of Kimura's disease had been treated in our centre from year 2003 to 2010. All cases were presented with head and neck mass with cervical lymphadenopathy. Surgical excision was performed for all cases. Definite diagnosis was made by histopathological examination of the resected specimens. One out of five cases developed tumour recurrence four years after resection.

CONCLUSION

Surgical excision is our choice of treatment because the outcome is immediate and definite tissue diagnosis is feasible after resection. Oral corticosteroid could be considered as an option in advanced disease. However, tumour recurrence is common after cessation of steroid therapy.

Bilateral nontuberculous mycobacterial middle ear infection: a rare case

Nontuberculous Mycobacterium (NTM) middle ear infection is a rare cause of chronic bilateral intermittent otorrhea. We report a rare case of bilateral NTM middle ear infection in which a 55-year-old woman presented with intermittent otorrhea of 40 years' duration. The patient was treated medically with success. We conclude that NTM is a rare but probably under-recognized cause of chronic otitis media. A high index of suspicion is needed for the diagnosis to avoid prolonged morbidity. Treatment includes surgical clearance of infected tissue with appropriate antimycobacterial drugs, which are selected based on culture and sensitivity.

Optimal Size AMBU® Laryngeal Mask Airway Among Asian Adult Population

AIM

This was a randomized single blinded study to determine optimal size for Ambu®LMA (ALMA) among Malaysian adult population.

METHODS

One hundred and twenty six non-paralyzed anaesthetized adult patients were block randomized into size 3, 4 and 5 Ambu®LMA. Optimal size is defined primarily by oropharyngeal pressure (OLP). Pharyngeal injury and ease of insertion are also taken into consideration.

RESULTS

Mean OLP was significantly higher for Size 4 and 5 compared to size 3 (p<0.001) but similar between size 4 and 5. Number of insertion attempts and insertion time were similar between sizes. Size 5 required more manipulations during insertion (p<0.005) and had higher pharyngeal injury (p=0.001) compared to size 3 and 4.

DISCUSSION

We recommend size 4 ALMA as the optimal size for Malaysian adults in view of the higher OLP compared to size 3, yet less pharyngeal injury than size 5 in spontaneously breathing patients.

Intrasellar pituitary mucocele: diagnostic dilemma

Isolated intrasellar pituitary mucocele following transsphenoidal sinus surgery is extremely rare. The clinical features resemble a pituitary tumor, therefore careful radiological interpretation is crucial to reach the correct diagnosis. We report a case of intrasellar mucocele who had transsphenoidal sinus surgery performed 15 years prior.

Primary lacrimal sac lymphoma with recurrence: a case report

Primary lacrimal sac lymphoma is rare. The common clinical features are epiphora and medial canthal swelling which mimic nasolacrimal duct obstruction. Histological examination is therefore important to avoid delay in diagnosis and treatment. We report a case of primary lacrimal sac lymphoma in a 72-year-old female who developed a metachronous tumour at the hard palate one year after excision of the lacrimal sac tumour.

A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications

Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

Reconstruction of the pedicled nasoseptal flap donor site with a contralateral reverse rotation flap: technical modifications and outcomes

OBJECTIVES/HYPOTHESIS

A pedicled nasoseptal flap is our preferred reconstructive technique after endoscopic endonasal skull base surgery. Its harvesting implies that the donor site (septal cartilage) is left bare. Secondary healing leads to crusting at the donor site that negatively affects the patient's quality of life and requires multiple outpatient debridements. A nasoseptal reverse rotation flap was designed to eliminate this problem; however, its outcomes have not been reported.

STUDY DESIGN

Retrospective review.

METHODS

We retrospectively reviewed the clinical charts of patients who underwent endoscopic endonasal skull base surgery at the Wexner Medical Center at The Ohio State University from November 2010 to September 2012, and in whom a reverse flap was used. We analyzed patients' demographics, pathology, and outcomes regarding the reverse flap.

RESULTS

Forty-nine patients with various pathologies were included (11 meningiomas, seven craniopharyngiomas, five pituitary macroadenomas, five chondrosarcomas, five meningoencephaloceles, three chordomas, 11 malignant tumors, two other lesions). There were two patients lost to follow-up. Mean follow-up time was 11 weeks (range = 1-39 weeks). A follow-up examination 1 to 2 weeks after surgery revealed a complete re-epithelialization in 46 of 47 patients (97.87%). Adverse events included granuloma (n = 1), anterior dehiscence (n = 1), and excoriated mucosa (n = 1). Factors such as underlying disease, prior chemoradiotherapy, and postoperative chemoradiotherapy did not seem to affect the healing of the reverse flap.

CONCLUSIONS

The reverse flap provides complete remucosalization of the denuded donor septum, decreasing septal crusting within the first 1 to 2 postoperative weeks, and adds minimal morbidity.

Antibiotic sensitivity and spectrum of bacterial isolates in otorhinolaryngological infection: a retrospective study

OBJECTIVES

To identify the common bacteria of otorhinolaryngological (ORL) infection in three general hospitals in the state of Sarawak, East Malaysia and to determine the antibiotic sensitivity of the common bacteria to update local antibiotic policy.

METHODS

All specimens with positive monoclonal culture, received from inpatient and outpatient Otorhinolaryngology Department in the year 2009 and 2010 were included in the study. Patients' demographics, nature of specimens, bacterial isolates and antibiotic sensitivity were analysed by using the Statistical Package for the Social Sciences (SPSS).

RESULTS

A total 244 positive monoclonal cultures were identified. Staphylococcus species and Gram negative bacilli were the commonest bacteria of ORL infections. Common ORL bacteria remain sensitive to our front line antibiotics. There are a number of multi-drug resistant isolates of MRSA, ESBL Klebsiella pneumoniae and Acinetobacter baumanii in the hospital-acquired infections.

CONCLUSION

Although resistance to antimicrobial agents is growing worldwide, first line antibiotics still show significant therapeutic advantage in our local setting. The low resistance of bacterial isolates in our community reflects judicious use of antibiotics in our routine clinical practices.

Congenital cholesteatoma presenting with Luc's abscess

Congenital cholesteatoma (CC) rarely presents with Luc's abscess. As a result of widespread usage of antimicrobial agents, Luc's abscess is hardly encountered in current clinical practice. Herein, we report a case of Luc's abscess as the first presenting symptom in a 5-year-old boy with underlying CC. Patient's clinical findings, radiological investigations and treatment were also discussed.

Vibrant soundbridge: a new implantable alternative to conventional hearing AIDS in children

The Vibrant Soundbridge is a new middle ear implantable hearing device. It was first introduced for adult patients with moderate to severe sensorineural hearing loss. With the innovation of the surgical techniques, its usage had been broadened for children and those patients with conductive and mixed hearing loss. We report first two cases of monoaural Vibrant Soundbridge implantation in Malaysia. They were children with bilateral conductive hearing loss who had failed to benefit from previous hearing aids. Floating mass transducers were attached in oval window and long process of incus respectively. Remarkable hearing yield was observed without surgical complication.

Cervical schwannoma: report of four cases

Extracranial schwannomas in the head and neck region are rare neoplasms. The tumours often present as asymptomatic, slowly enlarging lateral neck masses and determination of the nerve origin is not often made until the time of surgery. Preoperative diagnosis maybe aided by imaging studies such as magnetic resonance imaging or computed tomography, while open biopsy is no longer recommended. The accepted treatment for these tumors is surgical resection with preservation of the neural pathway. We report four cases of cervical schwannomas that we encountered at our center during four years of period. The clinical features, diagnosis and origin, management and pathological findings of these benign tumors are discussed.

Endolymphatic sac tumour

We present a case of a papillary tumour at the cerebellopontine angle in a 41-year-old man. He presented with left-sided facial and ear pain associated with dizziness, nystagmus and hearing loss. CT scan of the temporal bone showed a destructive tumour at the left cerebellopontine angle. Surgical excision was performed and the diagnosis of the endolymphatic sac tumour was made. Endolymphatic tumour is a low grade adenocarcinoma that originates from the endolymphatic sac. The definitive diagnosis requires a combination of clinical features, radiological finding and pathological correlation.

An extensive cervical vagal nerve schwannoma: a case report

Vagal nerve schwannoma is extremely rare. The majority of cases present with a slow growing neck swelling without neurological deficit. Magnetic resonance imaging is the gold standard investigation to establish a pre-operative diagnosis. We report a case of a 32-year-old man with an extensive right vagal nerve schwannoma involving the right jugular foramen and parapharyngeal space. The tumour was resected via a transcervical approach. Complete excision of the tumour is the key to prevent recurrence.

Infrasellar craniopharyngioma of the posterior nasal septum: a rare entity

OBJECTIVE

To report an unusual location of infrasellar craniopharyngioma in a peadiatric patient.

CASE REPORT

A six-year-old boy presented with persistent bilateral nasal obstruction for one year. Clinical examination revealed a posterior choanal mass arising from septum and the finding was confirmed by paranasal sinuses computed tomography scan. He then underwent wide local excision. Histopathological examination confirmed the diagnosis of craniopharyngioma (adamantinomatous type). There were no signs and symptoms of recurrence after a year of followup.

CONCLUSION

Infracranial craniopharyngioma without sellar involvement is extremely rare. Persistent nasal obstruction without endocrine dysfunction is the common presentation. Radiological imaging is important to diagnose and assess the extent. The mainstay of treatment for infrasellar craniopharyngioma is surgery. Regular follow up is mandatory.

Review of ear, nose and throat foreign bodies in Sarawak General Hospital. A five year experience

OBJECTIVE

Ear, nose and throat foreign bodies are common in ENT clinical practice. This study was designed to establish the local data of otorhinolaryngeal foreign bodies in term of prevalence among paediatric and adult groups, the clinical features, types of foreign body at different sites, and laterality of foreign bodies.

METHOD

This study was carried out at ENT department, Sarawak General Hospital, Malaysia, from 1st January 2005 to 31st December 2009. A total of 1084 cases were included and statistically analyzed.

RESULT

Ear foreign bodies showed the highest incidence which was consisted of 480 (44.3%) cases, followed by nose in 270 (24.9%) cases, pharynx in 251 (23.2%) cases, esophagus in 57 (5.3%) cases and laryngo-tracheobronchial tree in 26 (2.4%) cases. Otorhinolaryngeal foreign bodies occurred more frequently in 0-10 year old age group which constituted 651 (60.1%) cases. The descending order of frequency for foreign body sites in adult was pharynx (17.2%), ear (12.8%), esophagus (3.1%), nose (1.7%) and laryngo-tracheobronchial tree (1.1%). The type of foreign bodies varies with age group and site of foreign body lodgement. In general, common foreign bodies in both adult and children were food related, with the additional of small objects such as plastic toy in paediatric group.

CONCLUSION

Otorhinolaryngeal foreign bodies were found more frequently in children. The types of foreign body were different from age group and sites of foreign body lodgement. The local food constituted the highest incidence of ear, nose, and throat foreign bodies with additional of plastic toys in paediatric group.

An unusual entry site of an intraorbital foreign body in a child

Intraorbital foreign bodies (IOrbFB) are associated with both sight and life threatening injuries. We report a case of an IOrbFB associated with retrobulbar hemorrhage and injury of the frontal sinus in an 11 year-old boy, after history of fall from the tree. Imaging studies revealed a metallic foreign body (FB) in the orbit and fracture of the walls of the frontal sinus. The usual entry route of an IOrbFB is either through the eye or orbital walls and extremely rare through the paranasal sinuses. This is the first reported case of a FB entering the orbit through the frontal sinus.

Head and neck cancer: possible causes for delay in diagnosis and treatment

OBJECTIVE

To explore the possible causes for delay in diagnosis and treatment of head and neck cancer at Sarawak General Hospital (SGH).

STUDY DESIGN

This is a prospective study of time interval between onset of symptom, first medical consultation, first specialist clinic consultation, diagnosis and treatment of head and neck cancer in otorhinolaryngology head and neck (ORL-HNS) and dental clinics at Sarawak General Hospital. Forty-two consecutive cases diagnosed to have cancer between July to December 2006 were studied.

RESULTS

Mean interval between onset of symptom and medical consultation was 3.8 months, mean interval between first medical consultation to ORL-HNS or dental clinic referral was 8.4 weeks, mean duration between first ORL-HNS or dental specialist consultation to histopathological diagnosis was 18.8 days while duration between diagnosis to definite treatment was 26.9 days.

CONCLUSION

Most cases were diagnosed at advanced stage. Patient delay was the main problem. There was significant delay by frontier health workers in identifying sinister symptoms of malignancy. Timing for diagnosis and treatment after specialist referral were comparable with other published studies.

A recurrent nasopharyngeal carcinoma with lacrimal sac involvement: a case report

We report a very rare case of recurrent nasopharyngeal carcinoma with local involvement of lacrimal sac. The patient was treated with chemotherapy and there was no recurrence noted after 1 year of follow-up.

Aneurysmal bone cyst of the maxilla

An aneurysmal bone cyst is a rare bone lesion. Its origin and precise nature remain unknown. It is seen as a locally-destructive, rapidly expandable, benign multicystic mass. We report a 17-year-old boy with an aneurysmal bone cyst of the maxilla, with extensive local involvement and bony destruction that was treated surgically. There was no recurrence noted after four years of follow-up.