Transtubular Transoral Approach for Irreducible Ventral Craniovertebral Junction Compressive Pathologies: Surgical Technique and Outcome.

Introduction: To investigate the use of a tubular retractor to provide access to the craniovertebral junction (CVJ) sparing the soft palate with the aim of reducing complications associated with traditional transoral approach but yet allowing adequate decompression of the CVJ. Materials and methods: Twelve consecutive patients with severe myelopathy (JOA-score less than 11) from ventral CVJ compression were operated between 2014-2020 using a tubular retractor assisted transoral decompression. Results: All patients improved neurologically statistically (p=0.02). There were no posterior pharynx wound infections or rhinolalia. There was one case with incomplete removal of the lateral wall of odontoid and one incidental durotomy. Conclusions: A Tubular retractor provides adequate access for decompression of the ventral compression of CVJ. As the tubular retractor pushed away the uvula, soft palate and pillars of the tonsils as it docked on the posterior pharyngeal wall, the traditional complications associated with traditional transoral procedures is completely avoided.

Transtubular Transoral Approach for Irreducible Ventral Craniovertebral Junction Compressive Pathologies: Surgical Technique and Outcome

@#Introduction: To investigate the use of a tubular retractor to provide access to the craniovertebral junction (CVJ) sparing the soft palate with the aim of reducing complications associated with traditional transoral approach but yet allowing adequate decompression of the CVJ. Materials and methods: Twelve consecutive patients with severe myelopathy (JOA-score less than 11) from ventral CVJ compression were operated between 2014-2020 using a tubular retractor assisted transoral decompression. Results: All patients improved neurologically statistically (p=0.02). There were no posterior pharynx wound infections or rhinolalia. There was one case with incomplete removal of the lateral wall of odontoid and one incidental durotomy. Conclusions: A Tubular retractor provides adequate access for decompression of the ventral compression of CVJ. As the tubular retractor pushed away the uvula, soft palate and pillars of the tonsils as it docked on the posterior pharyngeal wall, the traditional complications associated with traditional transoral procedures is completely avoided.

Evaluation of Retinal Nerve Fiber Layer Thickness and Optic Nerve Head Parameters in Obstructive Sleep Apnoea Patients

Purpose@#To study the retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) parameters in obstructive sleep apnoea (OSA) patients and their relationship with severity of the disease. @*Methods@#A cross-sectional, hospital-based study. Fifty-four OSA subjects and 54 controls were recruited. Candidate that fulfil the criteria with normal ocular examinations then proceed with spectrum domain Cirrus optical coherence tomography examinations. ONH parameters and RNFL thickness were evaluated. Apnoea-hypopnoea index (AHI) of the OSA group were obtained from the medical record. @*Results@#In OSA, mean of average RNFL thickness was 93.87 µm, standard deviation (SD) = 9.17, p = 0.008 (p < 0.05) while superior RNFL thickness was 113.59 µm, SD = 16.29, p ≤ 0.001 (p < 0.05). RNFL thickness fairly correlate with severity of the disease (AHI), superior RNFL with R = 0.293, R2 = 0.087, p = 0.030 (p < 0.05), and nasal RNFL R = 0.292, R2 = 0.085, p = 0.032. No significant difference and correlation observed on ONH parameters. In control group, mean of average RNFL thickness was 98.96 µm, SD = 10.50, p = 0.008 (p < 0.05) while superior RNFL thickness was 125.76 µm, SD = 14.93, p ≤ 0.001 (p < 0.05). @*Conclusions@#The mean of the average and superior RNFL thickness were significantly lower in the OSA group compare to control. Regression analysis showed RNFL thickness having significantly linear relationship with the AHI, specifically involving the superior and nasal quadrant.

Evaluation of Retinal Nerve Fiber Layer Thickness and Optic Nerve Head Parameters in Obstructive Sleep Apnoea Patients

Purpose@#To study the retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) parameters in obstructive sleep apnoea (OSA) patients and their relationship with severity of the disease. @*Methods@#A cross-sectional, hospital-based study. Fifty-four OSA subjects and 54 controls were recruited. Candidate that fulfil the criteria with normal ocular examinations then proceed with spectrum domain Cirrus optical coherence tomography examinations. ONH parameters and RNFL thickness were evaluated. Apnoea-hypopnoea index (AHI) of the OSA group were obtained from the medical record. @*Results@#In OSA, mean of average RNFL thickness was 93.87 µm, standard deviation (SD) = 9.17, p = 0.008 (p < 0.05) while superior RNFL thickness was 113.59 µm, SD = 16.29, p ≤ 0.001 (p < 0.05). RNFL thickness fairly correlate with severity of the disease (AHI), superior RNFL with R = 0.293, R2 = 0.087, p = 0.030 (p < 0.05), and nasal RNFL R = 0.292, R2 = 0.085, p = 0.032. No significant difference and correlation observed on ONH parameters. In control group, mean of average RNFL thickness was 98.96 µm, SD = 10.50, p = 0.008 (p < 0.05) while superior RNFL thickness was 125.76 µm, SD = 14.93, p ≤ 0.001 (p < 0.05). @*Conclusions@#The mean of the average and superior RNFL thickness were significantly lower in the OSA group compare to control. Regression analysis showed RNFL thickness having significantly linear relationship with the AHI, specifically involving the superior and nasal quadrant.

From the MJM Editors' Desk: Common errors authors make in submission to the Medical Journal of Malaysia.

Proper understanding the 'Instructions to authors' for a particular journal is the key towards successful submission of a manuscript which will lead to it being published. Common errors that are frequently made by authors in their submission to the Malaysia Journal of Malaysia (MJM) that lead to rejection of their submission or requiring major revisions or minor revisions are listed and discussed in this article. Outright rejection prior to even a peer review process may be made for an article due to: it is poorly written or when there is suspicion on the authenticity of the submission, which contains elements that are suspected to be plagiarised, it is a duplicate submission or not in the format required by the MJM. The editor in charge of the issue makes a recommendation to the Editor in Chief for the final decision.

Severe Cervicothoracic Kyphoscoliosis in Neurofibromatosis - A Failure Of Posterior-Only Instrumentation: A Case Report.

Treatment of severe spinal deformities associated with neurofibromatosis has proven to be challenging. An 11-year-old girl, with neurofibromatosis and severe cervicothoracic kyphoscoliosis, was initially treated with posterior instrumentation and fusion. Implant failure developed within a year, requiring an anterior stabilisation and fusion with a non-vascularised fibular strut graft for better stability and increased likelihood of achieving union. The posterior instrumentation was removed due to its prominence and wound breakdown. Following the removal of the posterior implant, the fibular graft fractured. The patient was maintained on a cervical collar until union was achieved. Posterior spinal fusion alone in severe spinal deformities in neurofibromatosis has a high risk of failure. A combined anterior and posterior fusion may increase the chance of success, with better stability and union rate.

Severe Cervicothoracic Kyphoscoliosis in Neurofibromatosis - A Failure Of Posterior-Only Instrumentation: A Case Report

@#Treatment of severe spinal deformities associated with neurofibromatosis has proven to be challenging. An 11-yearold girl, with neurofibromatosis and severe cervicothoracic kyphoscoliosis, was initially treated with posterior instrumentation and fusion. Implant failure developed within a year, requiring an anterior stabilisation and fusion with a non-vascularised fibular strut graft for better stability and increased likelihood of achieving union. The posterior instrumentation was removed due to its prominence and wound breakdown. Following the removal of the posterior implant, the fibular graft fractured. The patient was maintained on a cervical collar until union was achieved. Posterior spinal fusion alone in severe spinal deformities in neurofibromatosis has a high risk of failure. A combined anterior and posterior fusion may increase the chance of success, with better stability and union rate.

Osteoradionecrosis in Subaxial Cervical Spine - a Rare and Devastating Complication: A Case Report.

Osteoradionecrosis, a rare complication of radiation therapy, is a slow progression disease which affects the surrounding structures of spinal components. It essentially weakens the soft tissue and bony configuration and can cause nerve impingement or cord compression. We describe a patient who underwent radiotherapy for thyroid cancer and presented with cervical kyphosis with anterolisthesis of C3/C4 and C4/C5 some 32 years later. We explore the role of anterior and posterior fusion, as well as hyperbaric oxygen therapy in promoting healing.

Osteoradionecrosis in Subaxial Cervical Spine - a Rare and Devastating Complication: A Case Report

Osteoradionecrosis, a rare complication of radiation therapy, is a slow progression disease which affects the surrounding structures of spinal components. It essentially weakens the soft tissue and bony configuration and can cause nerve impingement or cord compression. We describe a patient who underwent radiotherapy for thyroid cancer and presented with cervical kyphosis with anterolisthesis of C3/C4 and C4/C5 some 32 years later. We explore the role of anterior and posterior fusion, as well as hyperbaric oxygen therapy in promoting healing.

Diagnosis of upper aerodigestive tract tumours using autofluorescence endoscopy in south east asian patients.

Diagnosis of upper aerodigestive tract tumours using autofluorescence endoscopy in south east asian patients. OBJECTIVES: Autofluorescence is a highly sensitive, and specific, complementary diagnostic tool for the photodiagnosis of head and neck squamous cell carcinomas. Together with ease of use, these properties suggest that autofluorescence, used alongside white light endoscopy, could be a promising tool for the screening of high-risk populations. The aim of this study was to evaluate its effectiveness in detecting tumours involving the upper aerodigestive tract, in comparison with histopathologic examination. METHODOLOGY: A cross-sectional prospective study was carried out from June 2011 till March 2012. Forty-five patients with clinical evidence of suspicious lesions involving the upper aerodigestive tract were enrolled and examined using conventional white light, and autofluorescence endoscopy. A biopsy of each lesion was subsequently submitted for histopathologic examination. RESULTS: Using histology as our gold standard, we compared the sensitivity, specificity, and predictive values of autofluorescence endoscopy in detecting upper aerodigestive tract tumours. In comparison to histopathologic examination, the sensitivity of autofluorescence endoscopy was 95%, with a specificity of 74% (P value<0.001). The positive and negative predictive values were 78%, and 94% respectively. These data confirm a statistically significant correlation between autofluorescence and histopathologic diagnoses. CONCLUSIONS: Autofluorescence endoscopy was effective in detecting upper aerodigestive tract tumours, with excellent discrimination between benign and malignant phenotypes; this methodology is an ideal adjunct to white light endoscopy.

Anatomical variants of surgically important landmarks in the sphenoid sinus: a radiologic study in Southeast Asian patients.

PURPOSE: Failure of a surgeon to understand the local variations of the anatomical landmarks of the sphenoid sinus is a potential risk factor to cause damage to the optic nerve (ON) or internal carotid artery (ICA) that lies on the walls of the sphenoid sinus. The aim of this study was to identify the anatomical variants of the sphenoid sinus and its related surrounding structures among the Southeast Asian (SEA) population, based on computed tomography (CT) scans. MATERIALS AND METHODOLOGY: This cross-sectional study analyzed 300 CT scans of the brain, paranasal sinuses (PNS), and head and neck (H&N) at a tertiary referral centre in Malaysia utilizing the Osirix software. The images were reconstructed into 1 mm cuts on bone window. Demographic details and scan findings were documented in a standardized data collection sheet. RESULTS: The rates of ON dehiscence, ICA dehiscence and ICA protrusion in the SEA population were 7.0, 3.0 and 10.0 %, respectively. The rate of ON protrusion was 2.3 %. There was no statistically significant relationship (p > 0.05) noted on Chi-square test, between anterior clinoid process (ACP) pneumatization and ON protrusion. The rate of Onodi cells in our population was 14.3 %. The average vertical distance of the ostia from the roof of the posterior choanae was 1.42 cm (±0.32). The horizontal distance of the ostia from the anterior end of the superior turbinate was 1.58 cm (±0.41) and the oblique distance of the ostia from the anterior nasal spine was 5.35 cm (±0.48). Independent t tests showed that there is a statistically significant difference between the means of each of these parameters (p < 0.001) and their international averages. CONCLUSION: The rate of ON protrusion is lower in the SEA population, whereas the rates of ON dehiscence, ICA dehiscence and ICA protrusion fall within the range of international averages. In our population, ACP pneumatization is not related to ON protrusion. The distance of the ostia from given landmarks was significantly shorter than in other studies.

Patterns of nasal foreign body in northeast Malaysia: A five-year experience.

OBJECTIVE: The aim of this study was to determine the common presentations and management outcomes in case of nasal foreign body. MATERIAL AND METHOD: A retrospective study was carried out over 5 years, from January 2008 to December 2012. The total number of patients was 43; maximum age was 9 years. Patient biodata, clinical presentation, type of foreign body and management outcome were obtained and analyzed from the medical records of the Universiti Sains Malaysia Hospital. RESULTS: Of the total 43 patients, 60.5% were male and 39.5% female. The most frequent age at which nasal foreign bodies were found was 3 years (48.83%) and the least frequent age bracket was 7-9 years (2.33%). Most patients had foul smelling nasal discharge (34.88%) or were asymptomatic (34.88%); the least common presentation was nasal discomfort (2.33%). Seeds (23.26%) were the most common foreign body, followed by rubber and batteries (16.28%). In most cases (58.14%), the foreign body had been inserted into the right nostril; 39.53% were inserted into the left nostril, and 2.33% were bilateral. Foreign bodies were removed under general and local anesthesia in 53.49% and 41.86% of cases respectively; 4.65% were dislodged spontaneously. CONCLUSION: Nasal foreign bodies are encountered daily in our routine clinical practice in the pediatric age group. General anesthesia is required in uncooperative agitated patients to avoid complications.

Trapezius Rotational Flap for Cervico-thoracic Wound Breakdown in Post-radiotherapy Necrosis : A Case Report.

ABSTRACT: The management of post-radiation wound breakdown over the posterior cervico thoracic region can be a challenging task for a surgeon. The aim of the treatment is to produce a well vascularized and a low tensile flap which will close a large defect. We describe the use of the lower trapezius flap to reconstruct the wound breakdown and to obtain stable tissue coverage in a patient with postradiation necrosis. This flap minimizes the disruption of the scapula-thoracic function while preserving the range of movement over the shoulder. From the literature review, it was noted that the dorsal scapular artery (DSA) and transverse cervical artery (TCA) aid in the blood supply to the trapezius muscle and prevent local necrosis during rotation of the flap. The trapezius flap is widely accepted because of the minor donor site morbidity, large arc of rotation and adequate blood supply. KEY WORDS: lower trapezius flap, scapula-thoracic function, postradiation necrosis.

Anatomical variations of the sphenoid sinus and its adjacent structures: a review of existing literature.

The sphenoid sinus, one of the posterior groups of sinuses, has long been regarded as a 'neglected sinus' due to the anatomical location, poor understanding and poor accessibility, till the advent of endoscopes and modern imaging techniques. Increasing knowledge and greater understanding of this sinus has permitted an evolution in surgical practices and boundaries. Various literatures of the past report a great variety of rates of pneumatization, rates of optic nerve protrusion and dehiscence, as well as internal carotid artery (ICA) protrusion and dehiscence. One similarity noted among these studies is that the rates vary according to the ethnicity of the patients. Recommendations have also been made along the way with regard to modified surgical techniques. This review aims to describe the pneumatization of sphenoid sinus and the topographical relation of the optic nerve and ICA in different populations.

Comparing the morbidity of external laryngeal nerve injury in thyroid surgery with and without identifying the nerve using intraoperative neuromonitoring.

OBJECTIVE: To describe and determine the possibility of surgical trauma to the external branch of the superior laryngeal nerve and to assess the role of intraoperative neuromonitoring in thyroid surgery. DESIGN AND SETTING: Prospective, randomized, controlled study in a teaching Hospital Universiti Sains Malaysia (HUSM), Kota Bharu, Kelantan, Malaysia. SUBJECTS: Forty two patients of both genders, whom underwent thyroid surgery divided into two groups (21 patients control group and 21 patients study group) in HUSM and were randomly selected for our study. METHODS: The use of nerve monitoring and proper surgical technique of upper thyroid pole dissection followed by its lateralization and exposure of cricothyroid space were performed in each subject in study group in order to preserve EBSLN after its identification. In control group upper thyroid vessels were ligated close to the upper thyroid pole without any effort of EBSLN identification. RESULTS: Total of 42 (35 females and 7 males) patients who underwent thyroid surgery in a period of 2 years. Evaluation of all subjects 1 case in control group presented with symptoms of EBSLN injury. CONCLUSION: Intraoperative identification and neuromonitoring can avoid injury to the EBSLN and prevent its sequential changes in voice especially for those who professionally depend to their voice.

Habitual non-traumatic cricothyroid joint dislocation: a rare case of rotated larynx.

A case of a 21 year old gentleman is described, with no history of preceding trauma, presenting with intermittent dysphagia to solids and fluids for 4 years. Neck examination at rest was normal. However on deep inspiration, the right thyroid lamina protrudes or becomes more prominent. The patient is able to return the larynx to its normal position with manual manipulation. Laryngeal examination with fibreoptic scope during rest and deep breath shows gross rotation of the laryngeal structures for more than 60 degrees on deep breath, with the vocal cords axis rotated to the left side. Management was conservative.

Harmonic scalpel for a bloodless partial glossectomy: a case report.

Tongue surgery is almost always complicated by intraoperative bleeding. Its rich blood supply especially from the lingual vessels makes the operative field bloody. Electrocautery has been widely used to replace cold scissors in order to achieve better hemostasis. The use of ultrasonic harmonic scalpel for glossectomy is still new in this country. We report a case of partial glossectomy using the harmonic scalpel in a patient who had a squamous cell carcinoma of the lateral border of the tongue.

Unilateral adductor vocal cord palsy treated with the titanium vocal fold medializing implant (TVFMI).

Vocal cord palsy secondary to recurrent laryngeal nerve injury may be attributable to trauma, infiltrating neoplasm, congenital cardiac anomaly and others. Regardless the causes, majority of unilateral adductor palsy cases are usually managed by speech rehabilitation in order to allow compensation. In selected cases, medialization procedure may be required to achieve a complete glottal closure during phonation. Multiple techniques have been developed to achieve this goal. This case report illustrates the recent advancement in vocal fold medialization procedure, which has not been widely practiced in Malaysia.

Evaluation of irradiated salivary gland function in patients with head and neck tumours treated with radiotherapy.

INTRODUCTION: Radiotherapy is an important treatment modality for head and neck tumours. One of its major drawbacks is post-treatment salivary gland hypofunction. This study was performed to objectively evaluate the salivary gland function in post-irradiated head and neck tumour patients. METHODS: We performed a cross-sectional study of 30 patients with head and neck tumours who had received radiotherapy. Unstimulated and stimulated whole salivary flow rates were assessed in these 30 patients, and compared with those of 30 normal subjects. Unstimulated whole saliva was measured by the draining method, while the spitting method was used to collect stimulated whole saliva. RESULTS: Both unstimulated and stimulated whole salivary flow rates were significantly reduced in the irradiated patients, compared with the normal subjects. This difference was statistically significant (p = 0.0001). CONCLUSION: Salivary function in post-irradiated head and neck tumour patients (assessed as salivary flow rates) was significantly reduced compared with normal controls, suggesting marked salivary gland hypofunction.