Evaluation of the current bacteriological profile and antibiotic sensitivity pattern in chronic suppurative otitis media.

OBJECTIVE: To determine the current microbiological profile of chronic suppurative otitis media (CSOM), their antimicrobial sensitivity, their resistance pattern to locally available antibiotics and the appropriate antibiotic against isolated microorganisms causing CSOM. METHODS: This cross-sectional study involved 91 ear swab specimens obtained from patients clinically diagnosed with active CSOM. Swabs were cultured for microbial identification according to a standard protocol. We performed antibiotic susceptibility testing, using the modified Kirby-Bauer disc diffusion method, and the diameter of the inhibition zone was interpreted based Clinical Laboratory Standards Institute guidelines. RESULTS: Microbial growth was seen in 85 (93.4%) samples, but 6 (6.6%) samples had no growth. Among the samples with growth, 63 (69.2%) were monomicrobial, 13 (14.3%) were polymicrobial, and 9 (9.9%) were of mixed growth with more than three microorganisms. The most common bacteria isolated was Pseudomonas aeruginosa (32.6%) followed by Staphylococcus aureus (16.9%) and Klebsiella spp. (5.6%). The most sensitive antibiotics against P aeruginosa were ceftazidime, meropenem, piperacillin-tazobactam, and cefepime. S aureus showed the highest sensitivity toward rifampin, cefoxitin, and fusidic acid. CONCLUSIONS: The bacteriological profile of CSOM showed a high prevalence of P aeruginosa, followed by S aureus and Klebsiella spp. with different distributions in different age groups. We observed a declining pattern of their antibiotic sensitivity. It is important to be aware of the current trend of the bacteriological profiles and to revise the antibiotic regime according to both the sensitivity and age groups.Level of Evidence: NA.

A Rare Manifestation of Cervical Yolk Sac Tumor in an Unfortunate Infant.

Paediatric germ cell tumor is composed of various neoplasms which exhibit capricious clinical presentation and histological features depending on the age and the area of presentation. Yolk sac tumor is an extremely rare malignant tumor of embryonic origin which usually arises from the gonads. Its manifestation in the head and neck region is extremely rare. Here, we report a rare case of the malignant transformation of mature teratoma into yolk sac tumor of the neck in an infant. Diagnosis was confirmed following histopathological examination of the neck mass along with marked increase of the serum alpha-fetoprotein. The child unfortunately succumbed prior to chemotherapy. We highlight the challenge we faced in diagnosing and managing this rare entity. We would also like to recommend serial monitoring of serum alpha-fetoprotein in all patients with mature teratoma to detect malignant transformation early.

The Effectiveness of a Voice Care Program Among Primary School Teachers in Northeastern Malaysia.

OBJECTIVES: We sought to determine the effectiveness of a voice care program among primary school teachers in a northeastern district in Malaysia. METHODS: We conducted a randomized community trial in eight primary schools in a northeastern district in Malaysia. The self-administered and validated Malay-Voice Handicap Index-10 (M-VHI-10) questionnaire was used to assess overall voice handicap scores pre-intervention and eight weeks post-intervention. Teachers with a score of five or more (n = 86) were randomized into intervention (n = 41) and control groups (n = 45). The intervention group received portable voice amplifiers and vocal hygiene instruction, which was delivered by lectures and a booklet. The control group was not prescribed any intervention. RESULTS: The sociodemographic, lifestyle, and occupational characteristics of the teachers (except maximum number of students per class) were similar between both groups. The baseline M-VHI-10 scores between both groups were also comparable. After the intervention phase, there was a significant effect observed in the total M-VHI-10 scores (p = 0.021, F-stat (df): 5.33 (1,79)) between both groups after controlling for the maximum number of students per class. CONCLUSIONS: Our results support the use of voice amplification in adjunct with vocal hygiene instruction as a prevention and treatment modality to reduce voice handicap among teachers. Our study demonstrated encouraging evidence on the low-cost voice care program as well as the success of group and workplace-based approaches in the school setting.

Anatomical variations of anterior ethmoidal artery at the ethmoidal roof and anterior skull base in Asians.

PURPOSE: The variations of the anterior ethmoidal artery (AEA) in different populations should be recognized by surgeons to prevent unwarranted complications during surgery. The aim of this study was to assess the anatomical variations of AEA in Asian population. METHODS: A cross-sectional study of 252 AEA identified by computed tomography (CT) of the paranasal sinuses. The multiplanar CT images were acquired from SOMATOM® Definition AS+ and reconstructed to axial, coronal and sagittal view at 1 mm slice thickness. RESULTS: 42.5% of AEA was within skull base (grade I), 20.2% at skull base (grade II) and 37.3% coursed freely below skull base (grade III). The prevalence of supraorbital ethmoid cell (SOEC) and suprabullar cell (SBC) was 29.8% and 48.0%. The position of AEA at skull base has significant association with SOEC (p < 0.001), but not with SBC (p = 0.268). Type I Keros was 42.1% and Type 11 Keros was 57.9%. When lateral lamella's height is longer, the probability increases for AEA to course freely within the ethmoid sinus (p = 0.016). The mean distance of AEA from skull base was 1.93 ± 2.03 mm, orbital floor 21.91 ± 2.47 mm and nasal floor 49.01 ± 3.53 mm. CONCLUSIONS: The position of AEA at skull base depends on the presence of SOEC and length of lateral lamella, but not with SBC. When compared to European population, the mean distance between AEA and nasal floor is shorter in Asians.

Cervical Aerocele: A Rare Delayed Complication of Tracheostomy.

Acquired cervical aerocele in adults is a rare condition and its delay development after tracheostomy decannulation is reported rarely. Our patient presented eight years after tracheostomy decannulation with a compressible anterior neck mass that only appeared when she coughed and could be deflated using manual compression. The mass was situated suprasternal at the previous tracheostomy scar. Computed tomography scan showed a paratracheal air sac without significant defect at the tracheal wall. Surgical intervention is the best treatment for symptomatic patients. As in this patient, we advise direct laryngoscopy and bronchoscopy for diagnostic and therapeutic purposes in such cases. However, our patient refused any surgical intervention.

Validation of Bahasa Malaysia STOP-BANG questionnaire for identification of obstructive sleep apnea.

PURPOSE: The diagnosis of obstructive sleep apnea (OSA) by polysomnography (PSG) is time-consuming and expensive. The STOP-BANG questionnaire (SBQ) is an adequate screening tool and easily applied. We aimed to validate the Bahasa Malaysia version for use in sleep clinic. METHODS: A cross-sectional study was carried out in the sleep clinic. Standard forward-backward method was used for translation. Patients were required to answer a translated version of the questionnaire in Bahasa Malaysia and underwent a PSG study. Apnea-hypopnea index (AHI) of five and more was considered diagnostic. SBQ score was divided into two groups, less than 3 and 3 or more to determine its correlation with mild, moderate, or severe OSA. The reliability of the questionnaire was compared against that of the PSG result. RESULTS: We recruited 134 patients with mean age of 41.22 ± 12.66 years old. 9.7% patients have low risk, 48.5% moderate risk, and 41.8% high risk of OSA by SBQ scoring. 28.4% of patients had mild, 33.6% had moderate, and 38.0% had severe OSA by PSG. The Bahasa Malaysia version had sensitivity, specificity, and positive and negative predictive value of 61.42, 71.05, and 84.06 and 41.54% respectively. When the score is higher, the probability increases for patients to have moderate or severe OSA. SBQ score showed moderate value of agreement to AHI. CONCLUSIONS: The Bahasa Malaysia version of SBQ is a valid tool for the identification of OSA. It is useful to detect patients at risk for further investigation and management.

Validity and reliability of the Malay version of Sleep Apnea Quality of Life Index--preliminary results.

BACKGROUND: The objective of this study was to determine the validity and reliability of the Malay translated Sleep Apnea Quality of Life Index (SAQLI) in patients with obstructive sleep apnea (OSA). METHODS: In this cross sectional study, the Malay version of SAQLI was administered to 82 OSA patients seen at the OSA Clinic, Hospital Universiti Sains Malaysia prior to their treatment. Additionally, the patients were asked to complete the Malay version of Medical Outcomes Study Short Form (SF-36). Twenty-three patients completed the Malay version of SAQLI again after 1-2 weeks to assess its reliability. RESULTS: Initial factor analysis of the 40-item Malay version of SAQLI resulted in four factors with eigenvalues >1. All items had factor loadings >0.5 but one of the factors was unstable with only two items. However, both items were maintained due to their high communalities and the analysis was repeated with a forced three factor solution. Variance accounted by the three factors was 78.17% with 9-18 items per factor. All items had primary loadings over 0.5 although the loadings were inconsistent with the proposed construct. The Cronbach's alpha values were very high for all domains, >0.90. The instrument was able to discriminate between patients with mild or moderate and severe OSA. The Malay version of SAQLI correlated positively with the SF-36. The intraclass correlation coefficients for all domains were >0.90. CONCLUSIONS: In light of these preliminary observations, we concluded that the Malay version of SAQLI has a high degree of internal consistency and concurrent validity albeit demonstrating a slightly different construct than the original version. The responsiveness of the questionnaire to changes in health-related quality of life following OSA treatment is yet to be determined.

Tongue paraesthesia and dysgeusia post suspension laryngoscopy.

Suspension laryngoscopy is a common laryngeal procedure in Endolaryngeal microsurgery (ELMS). Oral mucosa and dental injuries are the known complications of the procedure. Nerve injury however is an infrequent encounter. We report a rare complication of lingual nerve injury which manifested as tongue numbness and altered taste following Endolaryngeal microsurgery procedure. The condition improved completely after few months of conservative management.

Bilateral pulmonary aspiration of teeth and the migration of a foreign body from one main bronchus to another.

INTRODUCTION: Foreign body aspiration in the adult airway is very rare. A neglected foreign body can occur when the patient is mentally challenged or is in an unconscious condition such as following trauma. The diagnosis can be delayed because there is no typical history of choking or breathing difficulty. OBJECTIVE: To report a case of bilateral pulmonary aspiration of avulsed teeth. One tooth migrated from the main bronchus on one side to the opposite side before removal. CASE SUMMARY: An unconscious, intubated elderly man was managed in ICU for one week before tracheostomy was performed. Bilateral pulmonary aspiration of teeth was diagnosed accidentally on routine chest radiographs two weeks later. Removal was done with rigid bronchoscopy. Extraction of the remaining loose teeth was performed. CONCLUSION: It is important to check for loose teeth in unconscious patients, especially those who warrant prolonged ventilation and oral toilet.

Assessment of 3-D nasal airway morphology in Southeast Asian adults with obstructive sleep apnea using acoustic rhinometry.

The aim of the present study is to investigate nasal airway morphology in Asian adults with and without obstructive sleep apnea (OSA) using acoustic rhinometry (AR), principal components analysis (PCA), and 3-D finite-element analysis (FEA). One hundred eight adult Malays aged 18-65 years (mean ± SD, 33.2 ± 13.31) underwent clinical examination and limited channel polysomnography, providing 54 patients with OSA and 54 non-OSA controls. The mean minimal cross section area 1 (MCA1) and the mean minimal cross sectional area 2 (MCA2) were obtained from AR for all subjects and subjected to t tests. The OSA and control nasal airways were reconstructed in 3-D and subjected to PCA and FEA. The mean MCA1 and MCA2 using AR were found to be significantly smaller in the OSA group than in the control group (p < 0.001). Comparing the 3-D OSA and control nasal airways using PCA, the first two eigenvalues accounted for 94% of the total shape change, and statistical differences were found (p < 0.05). Similarly, comparing the nasal airways using FEA, the 3-D mean OSA nasal airway was significantly narrower in the OSA group compared to the control group. Specifically, decreases in size of approx. 10-22% were found in the nasal valve/head of inferior turbinate area. In conclusion, differences in nasal airway morphology are present when comparing patients with OSA to controls. These differences need to be recognized as they can improve our understanding of the etiological basis of obstructive sleep apnea and facilitate its subsequent management.

Bilateral pulmonary aspiration of teeth and the migration of a foreign body from one main bronchus to another

Foreign body aspiration in the adult airway is very rare. A neglected foreign body can occur when the patient is mentally challenged or is in an unconscious condition such as following trauma. The diagnosis can be delayed because there is no typical history of choking or breathing difficulty.

Primary non-Hodgkins lymphoma of the lacrimal sac: mortality-related epiphora.

We report a case of primary non-Hodgkins lymphoma of the lacrimal sac in a 60-year-old Asian lady, who presented with persistent epiphora and recurrent medial canthal swelling. Primary lymphoma of the lacrimal sac is rare and it can be easily misdiagnosed. Delayed in diagnosis may be related to mortality. To minimize the risk of overlooking specific pathology it is important to assess the appearance of the lacrimal sac and its surrounding structures intraoperatively. Biopsy of the lacrimal sac is required in cases where specific pathology is suspected.

Laser posterior cordectomy for bilateral abductor vocal cord palsy : a case report.

Bilateral abductor vocal cord palsy is comparatively a rare vocal cord lesion, especially in a patient with no history of neck mass, previous surgery or trauma. Many patients are not stridulous. A patient presenting with stridor may need emergency airway management before the other treatment is commenced. We report a case of bilateral abductor palsy which required an emergency tracheostomy and subsequently a laser posterior cordectomy.