Middle Ear Neuroendocrine Tumor Mimicking As Chronic Otitis Media.

Neuroendocrine neoplasms (NEN) of the head and neck are a rare and diverse group of tumors. Here, we report a case of a 40-year-old man presenting with symptoms resembling chronic left otitis media, including left ear otorrhea, otalgia, and reduced hearing. Otoscopic examination revealed a whitish mass located behind the tympanic membrane. The patient underwent examination under anesthesia and left cortical mastoidectomy, and a histopathological examination of the middle ear biopsy indicated the presence of an epithelial tumor with neuroendocrine differentiation, suggestive of middle ear adenoma. A staging CT scan performed three months after the mastoidectomy showed a hypodensity in the middle ear cavity, with no significant bony erosion, which could potentially indicate a residual or recurrent tumor. Consequently, a radical mastoidectomy was performed. The histopathological examination confirmed the presence of middle ear adenoma with neuroendocrine differentiation.

A Novel Methylene Blue Guided Neopharynx Closure and a Review of Essential Applications in Otolaryngology.

Methylene blue has many usages in the field of otolaryngology. We describe a preliminary finding of methylene blue guided neopharynx closure after total laryngectomy. This technique can potentially reduce the risk of pharyngocutaneous fistula and has not been described in the literature. It is also handy in assisting junior surgeons to perform modified Connell suture during neopharynx reconstruction. Concurrently, we reviewed other essential applications of methylene blue in otolaryngology.

Isolated cervical lymph node sarcoidosis: a diagnostic challenge of a case report.

BACKGROUND: Sarcoidosis is a granulomatous disorder involving multi-systemic organs. Patients invariably have lung involvement but some may have extrapulmonary disease. Rarely, cervical lymphadenopathy is the only sign without mediastinal or pulmonary abnormalities. CASE PRESENTATION: We report a Malay male who complained of neck swelling exclusively. On imaging, multiple enlarged cervical lymph nodes deep to the sternocleidomastoid muscle were seen. An excision biopsy revealed non-caseating granulomas with epithelioid macrophages. Extensive investigations led to the diagnosis of isolated cervical lymph node sarcoidosis. CONCLUSIONS: Sarcoidosis can present as cervical lymphadenopathy alone, without mediastinal or lung disease. The presence of epithelioid granulomas on histopathology warrants the exclusion of other granulomatous diseases. Isolated cervical lymph node sarcoidosis is only diagnosed in the presence of consistent clinical and radiological findings. In this case, close monitoring for systemic sarcoidosis is important as it can manifest later in life.

Outcome of canalith repositioning manoeuvre in benign paroxysmal positional vertigo in children and adolescents: A systematic review.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is a debilitating condition that has been significantly described in adults. Recent data points out that BPPV occurs in children as well. Canalith repositioning manoeuvre (CRM) has shown promising results amongst adult patients with BPPV. OBJECTIVE: We reviewed the literature to determine the outcome of CRM in children and adolescents with BPPV. METHODS: A literature search was conducted over 1 month (March 2022). The primary outcome was defined as the resolution of positional nystagmus and symptoms, and secondary outcomes were determined by the presence of recurrence and the number of attempts of CRM. RESULTS: Ten articles were selected based on our objective and selection criteria. A total of 242 patients were included, with a mean of 10.9 years. BPPV was diagnosed based on history and positional nystagmus in all patients (100%). CRM was performed in 97.9% of patients, whereby 80.5% recovered following a single attempt of CRM. Recurrence of symptoms was identified in 10% of patients with no reported major complications. CONCLUSION: CRM has demonstrated promising results in children and adolescents. The quality of evidence is limited until a better-quality study involving randomised controlled studies with a larger sample size is completed.

Evaluation of auditory system in obstructive sleep apnea patients.

OBJECTIVES: Obstructive sleep apnea (OSA) has been associated with auditory dysfunction both to the cochlear and higher auditory pathways. However, available literatures presented conflicting results. We aimed to study the impact of OSA severity and their polysomnography parameters on hearing function. MATERIALS AND METHODS: A total of 44 patients were included after evaluation for sleep disorders and were divided into four groups in accordance with apnea-hypopnea index (AHI). Pure tone audiometry (PTA), distortion product otoacoustic emission (DPOAE) and auditory brainstem response (ABR) were compared in commensurate with the severity of AHI. Polysomnography oximetry parameters of oxygen desaturation index, mean SPO2, minimum SPO2 and percent SPO2 < 90% were correlated with their respective PTA, DPOAE and ABR results. RESULTS: There was no significant change in the PTA, DPOAE and ABR results in connection with AHI severity. However, we found significant correlations between mean SPO2 and percent SPO2 < 90% with ABR wave I, III and V absolute latencies. Minimum SPO2 was also significantly correlated with wave III peak latency changes. CONCLUSIONS: Mean SPO2, percent SPO2 < 90% and minimum SPO2 could be key prognostic indicators of central auditory dysfunction in OSA patients. These parameters should be explored further as indicators of OSA severity rather than utilizing AHI alone. The hypoxic burden derived could be a better predictor of auditory function abnormalities rather than one derived from AHI.

A Single Institution Cadaveric Study on Anatomical Variation of the Sublingual Gland Duct.

The purpose of this study was to conduct a cadaveric dissection study on the anatomical variation of the sublingual (SLG) excretory ducts and dictate an improved understanding of the anatomical communication between the SLG duct and submandibular (SMG) ducts. This study is carried out by standardized dissection of anterior floor of mouth in 6 formalin-fixed adult cadavers in Silent Mentor Workshop University Malaya in August 2020. The cadavers had no trace of scars, adhesions, signs of trauma or operation. SMG duct opening was identified lateral to the lingual frenulum through a papilla in the floor of mouth behind the lower incisor tooth. A horizontal incision line was done over floor of mouth just lateral to the opening. SMG duct and SLG was traced and skeletonized. Any presence of major duct arising from the SLG and its communication with SMG duct were investigated. We found there are 3 patterns of SLG excretory duct variants; (1) One major (Bartholin's) duct which open independently at its own orifice adjacent to the orifice of the Wharton's duct of SMG. (2) One major (Bartholin's) duct which joined into the Wharton's duct of SMG. (3) Absent of a major duct arising from SLG. The overall mean diameter of SLG ducts were 1.3 ± 0.41 and the mean length of SLG ducts were 18.5 ± 6.55. The overall mean diameter of SMG ducts was 2.6 ± 0.74 and the mean length of SMG ducts were 46.5 ± 6.57. Excretory ductal system of SLG showed great variations, not only between the different cadavers but also within the different sides of the same cadaver. Awareness of potential anatomical variations can aid in the accurate diagnosis and treatment of patients with salivary gland pathology as well as help surgeons reveal potential risk factor and avoid complications during surgical procedures in the floor of mouth.

Outcome of Eustachian Tube Balloon Dilation in Children: A Systematic Review.

OBJECTIVE: Eustachian tube dysfunction (ETD) is a chronic entity that has been historically managed with adenoidectomy and ventilation tube insertion. Recently, balloon dilation of the eustachian tube has shown promising results in recalcitrant eustachian tube dysfunction. We reviewed the literature to determine the outcome of eustachian tube balloon dilation in children. METHODS: A literature search was conducted for the period from 1990 to 2020 by searching several databases over a 1-month period (January 2021) according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews for Interventions. Primary outcome was defined as the success of the intervention determined by the resolution of symptoms, and secondary outcome was determined by revisions surgery and presence of complications. RESULTS: Only 7 articles were identified based on our objectives and selection criteria. All studies included are retrospective cohort case series (Level IV) and 1 cohort of matched controls (Level III). A total of 284 patients were included in this review, with a mean age of 7.8 years. A total of 463 balloon dilation were performed either bilaterally or unilaterally. The most common finding of ETD is middle ear effusion in 5 studies. Balloon dilation of eustachian tube was second-line treatment in 6 studies and first-line treatment in 1 study. Improvement of symptoms was identified in all studies through various assessments performed. Revision surgery was performed in 1 study with no major complications reported. CONCLUSIONS: Balloon dilation of the eustachian tube may be considered as an alternative procedure following failed standard treatment in children. The quality of evidence is inadequate to recommend widespread use of the technique until a better-quality study has been completed. Future randomized controlled studies with a large sample size are warranted to determine the efficacy of this procedure amongst children.

Distraction Breathing Exercise in Managing Inducible Laryngeal Obstruction in a Female Patient.

Inducible laryngeal obstruction (ILO) describes as inappropriate, episodic, reversible laryngeal closure during inspiration, occurring at the glottic and/or supraglottic level, in response to external triggers causing exertional breathing difficulties. We describe a case of a female patient with an underlying major depressive disorder who presented with sudden onset of stridor and tachypnoea, whereby the external trigger was psychogenic in origin. Bedside flexible nasopharyngolaryngoscopy (FNPLS) showed characteristic findings of paradoxical adduction of vocal cords during inspiration. Arterial blood gas analysis, routine blood tests, chest radiography, and computed tomography (CT) scan of brain, neck, and thorax excluded neurological or airway abnormality. Bedside distraction breathing exercise alleviated the stridor and tachypnoea. The patient was managed by supportive psychotherapy, speech therapy, and anti-reflux medication and was discharged well with resolution of her respiratory distress. We would like to highlight that meticulous history along with physical examinations are imperative especially amongst Otorhinolaryngologists as emergent airway management tracheostomy would have been unnecessary and cause more stress and burden to the patient as well as family members.

Valsalva manoeuvre to detect isolated hyoid bone fracture.

The hyoid bone fracture has traditionally been attributed to strangulation and hanging. Although rare, ensuing its vague presentation, hyoid bone fracture is oftentimes overlooked and missed, leading to delayed complications. Herein, we are reporting an overlooked hyoid bone fracture in a man who attempted suicide by strangulating himself, whereby Valsalva manoeuvre performed during bedside flexible nasopharyngolaryngoscopy revealed the fractured segment. As the patient was stable and asymptomatic, he was successfully managed conservatively. We would like to highlight the awareness of the Valsalva manoeuvre, which could elicit hyoid bone fracture as missing or overlooking the fracture may lead to devastating complications which may ensue, such as respiratory distress.

Laryngopharyngeal Reflux Among Patients Undergoing Bariatric Surgery.

PURPOSE: The effect of altered subsphincteric gastric volume and pressure after bariatric surgery on laryngopharyngeal reflux (LPR) remains largely unknown. This was a cross-sectional pilot study conducted between January 2018 and January 2019 to identify changes in LPR symptoms and signs in bariatric surgery patients presurgery and postsurgery. MATERIALS AND METHODS: Thirty-four patients listed for bariatric surgery in a single tertiary referral center were recruited, where 31 (77.4% female, mean age 46.3 ± 8.9 years) fulfilled the eligibility criteria. Of the eligible patients, 54.8% and 45.2% underwent sleeve gastrectomy (SG) and gastric bypass (GB), respectively. LPR symptoms were assessed using the self-reported reflux symptom index (RSI). Video-recorded endolaryngeal signs were scored using the reflux finding score (RFS) by two blinded otolaryngologists. Patients' presurgical and 3-month postsurgical body mass index (BMI), RSI, and RFS were determined. Patients were deemed as having LPR when RSI > 13 or RFS > 7. RESULTS: There was a significant correlation between the postsurgical RSI and RFS changes (Pearson's r = 0.474, p = 0.007). Of the 31 patients, 12.9% (RSI) and 6.4% (RFS) recovered from preexisting LPR, whereas 22.6% (RSI) and 3.2% (RFS) developed new de novo LPR postsurgery. The postsurgical mean RFS change improved significantly in the GB group compared with that of the SG group (p < 0.05). CONCLUSION: LPR is best assessed clinically using a multimodal approach (RSI and RFS). Bariatric surgery may worsen or lead to de novo LPR. Recognizing the LPR outcomes in these patients is paramount for optimal voice, speech, and swallowing functions.

Can bone wax cause cholesterol granuloma in the petrous apex? A case report.

BACKGROUND: Cholesterol granuloma (CG) is a rare entity but is the commonest lesion in the petrous apex. They are associated with chronic ear disease and previous temporal bone surgery. While bone wax has been known to cause foreign body reaction due to its non-resorbable property in the mastoid, it has not been documented to cause CG formation. CASE PRESENTATION: We described a 43 years old male who presented with a right mastoid swelling, nine years after a right retro-sigmoid craniotomy and excision for a cerebellopontine angle meningioma. He also had multiple cranial neuropathies involving trigeminal, facial and vestibulocochlear nerves. Temporal bone CT and MRI showed features suggestive of cholesterol granuloma with extensive bony erosions. He was treated with surgical excision and drainage where bone wax residues were found intraoperatively. Histopathological analysis of the lesion confirmed the diagnosis of cholesterol granuloma. Post-operatively, the mastoid swelling resolved and his recovery was uneventful. CONCLUSION: Our case showed that CG could manifest as a complication of bone wax usage in a neurosurgical procedure. Even though further study is needed to draw a definitive conclusion on this theory, we believe this paper will contribute to the current literature as it is the only reported case of cholesterol granuloma with bone wax as the possible causative agent. This is important so that surgeons are aware of this potential complication and use this haemostatic agent more judiciously.

A 4-year review of surgical and oncological outcomes of endoscopic endonasal transpterygoid nasopharyngectomy in salvaging locally recurrent nasopharyngeal carcinoma.

PURPOSE: To study the surgical and oncological outcomes of endoscopic endonasal transpterygoid nasopharyngectomy (EETN) in salvaging locally recurrent nasopharyngeal carcinoma (NPC). METHOD: This was a retrospective clinical record review study carried out at a tertiary centre from June 2013 until May 2017. A total of 55 locally recurrent NPC patients (rT1-rT4) underwent EETN performed by single skull base surgeon with curative intention with postoperative adjuvant chemotherapy but without postoperative radiotherapy. RESULTS: There were 44 (80.0%) males and 11 (20.0%) females, with mean age of 52.5 years. The mean operating time was 180 min (range 150-280 min). 85% (47/55) of patients achieved en bloc tumour resection. 93% (51/55) of patients obtained negative microscopic margin based on postoperative histopathological evaluation. Intraoperatively, one (1.8%) patient had internal carotid artery injury which was successfully stented and had recovered fully without neurological deficit. There were no major postoperative complications reported. During a mean follow-up period of 18-month (range 12-48 months) postsurgery, five patients (9.1%) had residual or recurrence at the primary site. All five patients underwent re-surgery. One patient at rT3 passed away 6 months after re-surgery due to distant metastasis complicated with septicaemia. The 1-year local disease-free rate was 93% and the 1-year overall survival rate was 98%. CONCLUSIONS: EETN is emerging treatment options for locally recurrent NPC, with relatively low morbidity and encouraging short-term outcome. Long-term outcome is yet to be determined with longer follow-up and bigger cohort study. However, a successful surgical outcome required a very experienced team and highly specialised equipment.

Neck stiffness in a post-irradiated nasopharyngeal carcinoma adult: An unusual diagnosis.

Nasopharyngeal carcinoma is a neoplasm commonly found in population of South East Asia. The mainstay of treatment is high dose irradiation. Complications from radiotherapy are not uncommon especially to those nearby structures such as vertebrae and spinal cord. A 57 year-old gentleman with nasopharyngeal carcinoma (NPC) who was treated with chemo-radiation (total of 35 fractions,70Gy) presented to us 6 months post therapy with bilateral nasal discharge and progressive neck stiffness. Nasoendoscopy showed inflamed nasophayngeal mucosa and Computed Tomography (CT) brain and cervical spine showed retropharyngeal and anterior epidural collection with extension into atlantoaxial bone and spinal cord compression. Histopathological specimen revealed features of chronic inflammations with multiple actinomycetes colonies. Our patient suffered severe neck stiffness and loss of sensations on both upper limbs. He was treated conservatively with Halo vest and intravenous antibiotics for 8 weeks and recovered fully. Irradiation in NPC is known to cause devastating complications to cervical spine such as osteoradionecrosis, osteomyelitis. It also renders tissues hypoxic and risk of getting rare infection like actinomycosis. This report can represent a great diagnostic and therapeutic challenge with differentials of tumor recurrence, osteoradionecrosis or osteomyelitis. Patients must be regularly followed up to look for possible cervical complications as a result from irradiation, to prevent devastating outcome or prognosis.

Endoscopic Transsphenoidal Resection of Craniopharyngioma.

Objectives To demonstrate, step-by-step, the technique and efficacy of endoscopic transsphenoidal approach in resection of a suprasellar craniopharyngioma. Design The video shows a step-by-step approach to the resection, covering the exposure, access, resection, and confirmation of resection and reconstruction. Setting The surgery was performed in the University of Malaya Medical Centre, a tertiary referral center in the capital of Malaysia. Participants Surgery was performed jointly by Professor Prepageran from the department of otorhinolaryngology and Professor Vicknes Waran from the division of neurosurgery. Both surgeons are from the University of Malaya. Video compilation, editing, and voice narration was done by Dr. Kong Yew Liew. Main Outcome Measures Completeness of resection and avoidance of intra- and postoperative complications. Results Based on intraoperative views and MRI findings, the tumor was completely resected with the patient suffering only transient diabetes insipidus. Conclusion Central suprasellar tumors can be removed completely via an endoscopic transsphenoidal approach with minimal morbidity to the patient. The link to the video can be found at: https://youtu.be/ZNIHfk12cYg .

Economic Burden of the Inadequate Management of Allergic Rhinitis and Urticaria in Asian Countries Based on the GA²LEN Model

PURPOSE: Across Hong Kong, Malaysia, the Philippines, Singapore, Thailand and Vietnam, (referred to as Asia) approximately 30–53 million individuals of the 151 million employed suffer from allergic rhinitis (AR) and urticaria. It is estimated that approximately 90% of patients with these allergic conditions are insufficiently treated, impacting the socioeconomic burden in terms of absence from work and decreased productivity. This study aims to estimate the socioeconomic burden of allergies in Asia and the cost savings that their adequate management can provide. Due to the limited availability of regional data, this study focused AR and urticaria in selected countries. METHODS: Published literature, information from statistical bureaus, clinician surveys and extrapolation of selected data from the European Union were used to determine the socioeconomic costs of AR and urticaria. RESULTS: Many patients in Asia suffer from perennial allergies and experience symptoms of AR and urticaria for up to 298 days per year. An estimate of the indirect costs of patients insufficiently treated for AR and urticaria amounts to USD 105.4 billion a year, which equates to USD 1,137–2,195 per patient due to absenteeism and presenteeism. Adherence to guideline-approved treatment can lead to estimated savings of up to USD 104 billion. CONCLUSIONS: The current study suggests that within Asia, the socioeconomic impact of AR and urticaria is similar to that seen in the European Union in spite of the lower wages in Asia. This is due to the mainly perennial allergens prevailing in Asia, whereas the sensitization patterns observed in the European Union are dominated by seasonal exposure to pollen. These results underline the need for governmental initiatives to increase public awareness on the prevention and treatment of these and other allergic diseases as well as greater research funding and large-scale studies to reduce their growing socioeconomic burden in coming years.

Challenges in the management of massive intraorbital and hemifacial arteriovenous malformation as causing life-threatening epistaxis.

Arteriovenous malformations are congenital lesions that may evolve with time and manifest in a plethora of presentations. They can occur as torrential epistaxis when it extensively involves the facial region. Multi-imaging modalities are available to assist in characterizing the structure of the lesion as well as its location and extent. This complex disease requires a multidisciplinary team approach with preoperative embolization and surgery. We present a rare cause of life-threatening epistaxis in a gentleman with a longstanding orbital and hemifacial arteriovenous malformation and discuss the complexities involved in its management.