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Purpose Nitric oxide (NO) is a potential marker in the diagnosis and monitoring of treatment for the management of patients with allergic rhinitis (AR). The study aimed to determine the value of nasal fractional exhaled nitric oxide (FeNO) in the diagnosis and treatment response of AR patients. Methods The participants were divided into control and allergic rhinitis groups based on the clinical symptoms and skin prick tests. The AR group was treated with intranasal corticosteroid after the diagnosis. The nasal fractional exhaled nitric oxide (FENO) levels were compared between control and AR groups. In the AR group, the visual analogue scale (VAS), Nasal Obstruction Symptoms Evaluation (NOSE) questionnaire, and nasal fractional exhaled nitric oxide (FeNO) were assessed pre- and post-treatment. Results One hundred ten adults were enrolled. The nasal FeNO level was significantly higher in AR compared to control ( p Conclusion Nasal FeNO level is significantly higher in AR compared to control group with significant difference pre- and post-treatment. The findings suggest nasal FeNO can serve as an adjunct diagnostic tool together with the monitoring of treatment response in AR.

Sistem pendidikan pada masa sekarang telah melalui satu fasa tranformasi ke arah pembelajaran berasaskan teknologi. Banyak pendekatan teknologi sudah diaplikasikan dalam pembelajaran sama ada di peringkat sekolah mahupun universiti. Penggunaan media baharu seakan-akan menjadi satu trend, kesan daripada pandemik Covid 19 yang melanda dunia pada masa sekarang. Pelajar telah didedahkan dengan platform atas talian seperti zoom, webex, you tube, Instagram, facebook, tik tok dan sebagainya untuk membuat persembahan tugasan. Oleh yang demikian, dalam kertas kerja ini akan melihat maklum balas pelajar terhadap penggunaan teknologi dalam pembelajaran bahasa Sepanyol peringkat asas di Universiti Putra Malaysia. Seramai 104 pelajar memberi maklum balas berkaitan dengan kepuasaan mereka mempelajari bahasa Sepanyol melalui penggunaan teknologi seperti you tube. Selain itu aplikasi atas talian untuk tujuan pembelajaran juga diperkenalkan seperti wordwall, duolingo, lingua.com, spanishspanish.com dan studyspanish.com. Objektif kajian adalah bertujuan untuk mengenal pasti pendekatan teknolgi digunakan dan menganalisis maklum balas pelajar terhadap pembelajaran bahasa Sepanyol berdasarkan penilaian pengajaran yang perlu dibuat. Secara rumusan berdasarkan hasil dapatan, kebanyakkan pelajar sangat berpuas hati dengan pendekatan teknologi yang digunakan oleh pensyarah.

Objective The aim of this study was to evaluate olfactory, gustatory, and quality-of-life outcomes in patients who underwent endonasal transsphenoidal hypophysectomy. Methods In this prospective study, the patients were assessed subjectively using the Malay version of sQOD-NS (short questionnaire of olfactory disorders in a negative statement) and objectively using the culturally adapted Sniffin’ Sticks smell test and taste test preoperatively and 3 months postoperatively. The Sniffin’ Sticks smell test consists of odor identification, odor discrimination, and odor threshold tests. The taste test consists of different sweet, salt, sour, and bitter concentrations. Results Twenty patients were enrolled in the study. The study comprises 45% female and 55% male. On average patients’ ages were 49.5 years. In this study we found a significantly reduced in odor identification score (p = 0.049) post-surgery; however, there was no statistically significant difference in odor threshold, odor discrimination, and taste. The olfactory quality of life outcome based on the Malay version of sQOD-NS (p = 0.001) was significantly reduced after surgery. There was no significant difference in the Sniffin’ Sticks smell test (p p p = 0.056). Conclusion The study showed that the endoscopic transsphenoidal technique for pituitary surgery does not pose permanent olfactory disability.

Background Sporotrichosis is a subcutaneous mycosis caused by a dimorphic fungus, Sporothrix schenckii infection, that usually results from the traumatic implantation of the fungus into the skin and subcutaneous tissue. Disseminated cutaneous sporotrichosis is a rare entity that usually presents in the immunosuppressed individual. They are sometimes mimicking malignancy and tuberculosis. Here, a rare case of disseminated cutaneous sporotrichosis involving the larynx and nasal cavity in an immunocompetent patient is reported. Case presentation A 54-year-old healthy lady presented with hoarseness and globus sensation over the throat with prior history of multiple skin lesions over the face, limbs, and trunk. Examination revealed erythematous papular lesions over the face, limbs, and trunk. Nasoendoscopy showed sloughy mucosa over bilateral nasal cavities, nasopharynx, base of the tongue, arytenoids, and both vocal folds with bony hard mass at the left frontal recess opening. Overall imaging features were suggestive of generalized fungal infections. Multiple biopsies from multiple sites revealed Sporothrix schenckii infection. She had resolution of the lesion after being treated with intravenous Amphotericin B for a month, oral Voriconazole for another month then oral Itraconazole for 6 months. Conclusion Diagnosis of disseminated sporotrichosis can be tricky and difficult to diagnose as it can mimic other diagnoses. Education is paramount important in identifying the illness as it can be seen in immunocompetent individuals, although it is more common in the immunosuppressed individual.

Background Score for Allergic Rhinitis (SFAR) is a validated self-administered questionnaire to assess for allergic rhinitis (AR) in a population setting but was designed for a temperate climate. Objective This study aims to modify the SFAR for the tropical climate, translate the modified SFAR from English to Malay Language, and validate this Malaysian version of SFAR (MySFAR). Methods This was a cross-sectional study at an outpatient Otorhinolaryngology clinic in a tertiary center. There were 2 phases in the study: (1) the translation and validation of SFAR and (2) the testing of diagnostic accuracy. Two different groups of participants were recruited for the respective phase. Results In phase 1, the total MySFAR score showed good discriminant validity between AR and healthy controls (13.44 ± 1.58 v 1.00 ± 2.12, p p p 9 (J = 0.92) was determined based on the highest Youden index. This cut-off was 97.8% sensitive and 93.9% specific to predicting allergic rhinitis from non-allergic rhinitis. Conclusion The present study showed good validity and reliability of MySFAR among the Malaysian population. The cut-off score of > 9 was able to predict allergic rhinitis. This would be a useful screening tool for allergic rhinitis population studies in tropical countries.

Pronunciation in second language learning is sometimes challenging, especially the vowels. Vowels such as [i] and [a] are found both in Hausa and Yorùbá but [i:] and [a:] are peculiar to Hausa alone. While Hausa has short and long vowels, Yorùbá has only oral and nasal vowels in their vowel inventories. Such phonemic differences constitute learning challenges, especially for the Yorùbá native speakers. This is a cross-sectional study design using mixed methods to examines the production of high front vowels: [i], and [i:], as well as low: [a], and [a:] Hausa vowels by the Yorùbá speakers to identify which group perform better between group 1 (Yorùbá native speakers who learned Hausa in the secondary school before going to the college of education), and group 2 (Yorùbá native speakers who learned Hausa informally before going to the college of education). The study also seeks to find out vowel substitutions that occur in the pronunciation tasks using 80 participants from 18 years old and above from the College of Education system in Nigeria who were selected based on purposive sampling. The findings were discussed in line with Flege & Bohn’s (2020) ‘Revised Speech Learning Model’. 8 stimuli were audio-recorded, transcribed, and rated by two independent raters, in addition to participant observation techniques adapted. The results of the Mann-Whitney test revealed that group 2 performed better than group 1. The study discovered also that the short [a] in the first and second syllables had the highest frequency of substitution compared to [i], [i:] and [a:] vowels. Such problems have pedagogical implications for learning Hausa as a second language.

The mid short vowels: /e/ and /o/ are among the vowels shared between Hausa and Yorùbá but differ in Hausa mid-high long, front and back vowels: /e:/ and /o:/. The phonemic differences in the two languages have caused learning difficulties among the Yorùbá native speakers to achieve their second language learning desire and competence. Yorùbá-Hausa learners mispronounce certain disyllabic Hausa words due to the substitution of vowels in the first and second syllables. Thus, both lexical and grammatical meanings of the Hausa words are affected. This study examined the production of the 12 Hausa vowels by level 1 and level 3 students who were learning Hausa as a second language to determine if there was a significant difference in how level 1 and level 3 students pronounced the short and long mid-high, front and back Hausa vowels. 88 Yorùbá native speakers were recruited using purposive sampling. Twenty-four different wordlists extracted from Bargery's (1934) Hausa-English dictionary and prepared in carrier phrases were audio-recorded. It was a mixed-method, and the results were discussed within the theoretical framework of Flege and Bohn's (2020) Revised Speech Learning Model and Corder's (1967) 'Error Analysis Model'. The results of the Mann-Whitney U test revealed that participants in level 1 generally performed lower than level 3 participants in the pronunciation of mid-Hausa vowels due to substitutions. Such errors have pedagogical implication in learning Hausa as a second language, and if not addressed accordingly, the standard of Hausa will continue to fall at an undesirable and alarming rate.

Nasal septal abscess and hematoma are rare clinical entities. To the best of our knowledge, there have only been 2 cases of nasal septal abscess associated with haematological malignancy reported in the literature. Herein, we present a unique case of recurrent spontaneous nasal septal hematoma and abscess in a patient prior to and after the diagnosis of acute myelogenous leukemia. Its rarity in immunocompromised population, clinical presentation, treatment and complications are further discussed.

Purpose The allergic phenotype of chronic rhinosinusitis (CRS) and central compartment atopic disease (CCAD) have been described. The CCAD is a radiological phenotype in patients with CRS that presents as a central mucosal disease due to allergy. The subset of patients having chronic rhinosinusitis with nasal polyps (CRSwNP) has not been well characterized. We aim to describe the clinical and radiological characterizations of patients presenting with the allergic phenotype of CRSwNP. Patients and methods A cross-sectional study at a tertiary hospital was performed. Adult patients diagnosed with CRSwNP who had both allergology and radiological assessments were enrolled. The symptoms of allergic rhinitis, Lund-Kennedy (LK) endoscopic scoring, Lund-Mackay (LM) computed tomography scan of paranasal sinuses (CTPNS) scoring, CCAD features, skin prick test (SPT) and level of specific IgE were assessed. All the patients underwent SPT for house dust mites. Results A total of 38 patients were enrolled. Symptoms, endoscopic and CTPNS scores were higher in the allergy and CCAD groups compared to the nonallergy and nonCCAD groups. The symptom of "need to blow nose" was statistically significant in allergy vs nonallergy (p=0.01) and CCAD vs nonCCAD (p=0.02). There were significant differences in the endoscopic scores in both allergy and CCAD (allergy vs nonallergy, p=0.01; CCAD vs nonCCAD, p=0.03), and CT scores in both allergy and CCAD (allergy vs nonallergy, p=0.02; CCAD vs nonCCAD, p=0.02). All patients with CCAD have worse scoring than nonCCAD (LK score, p=0.03; LM score, p=0.02). Patients with allergy have more polypoidal involvement of the middle turbinates (left middle turbinate, p=0.141; right middle turbinate, p=0.074) and CCAD (left middle turbinate, p=0.017; right middle turbinate, p=0.009) than nonallergy and nonCCAD patients. Conclusion Allergic phenotype of CRSwNP has a worse clinical and radiological disease burden. Optimal treatment of allergy is essential for a better outcome.

Baharudin Abdullah,1 Amir Hamzah Abdul Latiff,2 Anura Michelle Manuel,3 Faizah Mohamed Jamli,4 Harvinder Singh Dalip Singh,5 Intan Hakimah Ismail,6 Jeevanan Jahendran,2 Jeyasakthy Saniasiaya,7Kent Chee Keen Woo,8 Phaik Choo Khoo,9 Kuljit Singh,3 Nurashikin Mohammad,10 Sakinah Mohamad,1 Salina Husain,11 Ralph Mösges12,13 1Department of Otorhinolaryngology - Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia; 2Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia; 3Prince Court Medical Centre, Kuala Lumpur, Malaysia; 4Department of Paediatrics, Hospital Serdang, Selangor, Malaysia; 5Department of Otorhinolaryngology - Head and Neck Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak; 6Department of Paediatrics, Universiti Putra Malaysia, Selangor, Malaysia; 7Department of Otorhinolaryngology, Universiti Malaya, Kuala Lumpur, Malaysia; 8Gleneagles Hospital Kuala Lumpur, Kuala Lumpur, Malaysia; 9Subang Jaya Medical Centre (SJMC), Selangor, Malaysia; 10Department of Internal Medicine, Universiti Sains Malaysia, Kelantan, Malaysia; 11Department of Otorhinolaryngology-Head & Neck Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia; 12Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany; 13ClinCompetence Cologne GmbH, Cologne, GermanyCorrespondence: Baharudin Abdullah, Department of Otorhinolaryngology - Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia, Tel +60 97676416, Fax +60 97676424, Email baharudin@usm.my; profbaha@gmail.comAbstract: The goal of allergic rhinitis (AR) management is to achieve satisfactory symptom control to ensure good quality of life. Most patients with AR are currently treated with pharmacotherapy. However, knowledge gaps on the use of pharmacotherapy still exist among physicians, particularly in the primary care setting, despite the availability of guideline recommendations. Furthermore, it is common for physicians in the secondary care setting to express uncertainty regarding the use of new combination therapies like intranasal corticosteroid plus antihistamine combinations. Inadequate treatment leads to significant reduction of quality of life that affects daily activities at home, work, and school. With these concerns in mind, a practical consensus statement was developed to complement existing guidelines on the rational use of pharmacotherapy in both the primary and secondary care settings.Keywords: allergic rhinitis, pharmacotherapy, consensus, primary care, secondary care, Malaysia

An increase in the prevalence of allergic rhinitis (AR) worldwide presents a significant burden to the health care system. An initiative was started in Europe designated as Allergic Rhinitis and Its Impact on Asthma (ARIA) to develop internationally applicable guidelines by utilising an evidence-based approach to address this crucial issue. The efforts are directed at empowerment of patients for self-management, the use of digital mobile technology to complement and personalise treatment, and establishment of real-life integrated care pathways (ICPs). This guideline includes aspects of patients’ and health care providers’ management and covers the main areas of treatment for AR. The model provides better real-life health care than the previous traditional models. This review summarises the ARIA next-generation guideline in the context of the Malaysian health care system.

Antrochoanal polyps are occasionally encountered in an ear, nose and throat practice and most of them present with progressive unilateral nasal blockage. This paper depicts a pediatric patient’s peculiar presentation of an infected antrochoanal polyp along with obstructive symptoms as the stalk of the antrochoanal polyp which favours proliferative fasciitis could be a possible cause of an acute manifestation of the disease. The stalk, which was adherent to the medial wall of the maxillary sinus and anterior portion of the polyp was removed via intranasal endoscopic approach. Postoperatively, the patient was discharged well and after two years of follow-up, there were no signs of recurrence.

Allergic rhinitis (AR) is an IgE-mediated inflammatory disease of the upper airway. AR affects the patients’ quality of life, is a known risk factor for asthma and a socio-economic burden. Allergen-specific immunotherapy (AIT), comprising sublingual immunotherapy (SLIT) and subcutaneous immunotherapy (SCIT), involves administering increasing doses of the causative allergen to induce clinical and immunologic tolerance to the allergens. It is the only currently available treatment for AR that has been proven to induce disease-modifying effects (i.e., long-term remission of allergic symptoms or potential prevention of asthma and new sensitizations). Although AIT is conventionally recommended for patients who are non-responsive to symptom-relieving pharmacotherapy, it is presently recommended as a first-line treatment for patients with moderate to severe AR who prefer a treatment with the potential for long-term remission. In light of the relatively recent implementation of AIT in Malaysia, guidelines on its appropriate indication and application are important to attain optimal outcomes. This consensus statement was developed by an expert group formed by the Malaysian Society of Allergy and Immunology to provide evidence-based recommendations for the practice of AIT in Malaysia. Patient and product selection, choice of AIT, and strategy towards an effective treatment outcome in AIT are presented.

To evaluate the efficacy of topical tranexamic acid (TXA) in reducing intraoperative and immediate postoperative bleeding during functional endoscopic sinus surgery (FESS) among patients with chronic rhinosinusitis with nasal polyposis (CRSwNP).This is a double-blind randomized clinical trial, involving 26 patients with CRSwNP, who underwent FESS for failed medical therapy. The intervention nostril was packed with ribbon gauze soaked in 500 mg/5 ml TXA. The control nostril was packed with ribbon gauze soaked in Moffett's solution, containing 2 ml 10% cocaine, 1 ml adrenaline 1:1000, and 4 ml 0.9% sodium bicarbonate. Both nostrils were packed for 15 min before FESS. Intraoperative bleeding was recorded in the initial 30 min after commencing the surgery. The recordings were reviewed by two surgeons using Boezaart's scoring system. The scores were taken at 15 and 30 min of surgery. The mean score was then calculated. At the end of the surgery, the intervention nostril was packed with MerocelThere was no significant difference in intraoperative bleeding between the intervention (1.54 ± 0.71) and control nostrils (1.69 ± 0.55) with p = 0.172. The amount of bleeding in the postoperative period was significantly reduced in the intervention nostril (1.33 ± 0.55) compared to the control nostril saline (1.81 ± 0.48) with p = 0.001.We found that the nasal packing soaked in TXA reduced intraoperative and immediate postoperative bleeding. It is a safe, efficacious and cost-effective alternative to Moffett's solution during FESS and also an alternative to normal saline post-surgery among patients with CRSwNP.FF-2015-232, 2015.

Keros and Gera classifications are widely used to assess the risk of skull base injury during endoscopic sinus surgery. Although, both classifications are useful preoperatively to stratify risk of patients going for surgery, it is not practical to measure the respective lengths during surgery. In this study, we aimed to propose a new radiological classification (Thailand-Malaysia-Singapore (TMS)) to assess the anatomical risk of anterior skull base injury using the orbital floor (OF) as a reference. A total of 150 computed tomography images of paranasal sinuses (300 sides) were reviewed. The TMS classification was categorized into 3 types by measuring OF to cribriform plate and OF to ethmoid roof. Most patients were classified as TMS type 1, Keros type 2 and Gera class II, followed by patients classified as TMS type 3, Keros type 1 and Gera class 1. TMS has significant correlation with Keros classification (p

Introduction: Sniffin’ Sticks smell identification test is a tool used for evaluation of olfactory function but the results are culture-dependent. It relies on the subject’s familiarity to the odorant and descriptors. This study aims to develop the Malaysian version of Sniffin’ Sticks smell identification test suitable for local population usage. Materials and Methods: The odorant descriptors and distractors of the original version of Sniffin’ Sticks were translated into Malay language. It was then tested for familiarity and identifiability in 30 normosmic subjects. The descriptors were replaced until the familiarity of all descriptors and identification rates of odorants achieved ≥ 70%. The validity of the new cultural-adapted version was tested in 60 hypo-anosmic subjects and 60 normosmic subjects with Student t-test. The test-retest reliability was evaluated after two weeks with interclass correlation. Results: Two odorant descriptors and nine distractors achieved familiarity

Acute invasive fungal rhinosinusitis is a rare sinonasal infection. It usually occurs in immunocompromised patients. The presentation of acute invasive fungal rhinosinusitis with disseminated fusariosis mimicking varicella zoster cutaneous lesion is extremely rare in otorhinolaryngology practice. The morbidity and mortality rates in immunocompromised patient are high and determined by proper management of the disease. Therefore, appropriate investigation and management are very important. We describe a case of acute invasive fungal rhinosinusitis with disseminated fusariosis in a child presenting with cutaneous lesions mimicking varicella zoster associated with nasal pain and eschar. This report also emphasised the important role of an otorhinolaryngologist in the early diagnosis and management of acute invasive fungal rhinosinusitis.

The aim of this paper is to review and summarise the current knowledge of prevention of house dust mite (HDM)-induced allergic rhinitis (AR). AR can be either classified as seasonal/intermittent (for example hay fever occurring summer and autumn) or perennial/persistent (occurring throughout the year). The commonest trigger for seasonal AR is pollen whereas HDMs are the key allergic trigger for perennial AR. HDMs are a recognised indoor allergen that is crucial in the development of AR, asthma, and atopic dermatitis. Preventive strategies have gained acceptance for the management scheme in the treatment of patients with AR. Specifically, preventive measures include allergen avoidance, environmental control, and immunotherapy. The primary goal of medical treatment is to reduce the burden of disease, improve quality of life and to prevent the development of the sequelae of AR such as bronchial asthma. Prevention is a viable option and key component in HDM-AR management. As urbanisation and lifestyle changes lead to the increase of HDM-AR, there should be a more concerted effort towards prevention.

Introduction: Cultural backgrounds can influence the smell test because of the unfamiliarity of different populations with a number of odorants. The study aims to determine the cutoff points for hyposmia using the cultural adaptation of the Malaysian version of the Sniffin’ Sticks identification smell test among different age groups. Methods: In this cross-sectional study, healthy participants were recruited from a hospital, senior citizen homes, and schools from 2019 until 2021. Participants were divided into 5 different age groups (A: children, B: adolescents, C: young adults, D: middle-aged adults, and E: older adults) and underwent the identification smell test. Scores below the 10th percentile in these age groups were used to determine the cutoff points for hyposmia. Results: The cutoff points for the smell identification scores for hyposmia at the 10th percentile in children, adolescents, and adults (young, middle-aged, and older) were less than 6, 9, and 11, respectively. Pairwise comparisons were made using the Bonferroni post hoc test, with p < 0.001. Scores showed a significant difference between males (mean [SD]: 11.43 [2.42]) and females (12.01 [1.98]); p = 0.005. Conclusion: Our study found that the cutoff points of the identification smell test for hyposmia were lower than those of other studies. It is important to use these cutoff points in our population to establish the correct integrity of olfaction function in the clinic setting and in future research.

OBJECTIVES To assess olfactory abilities using a culturally adapted Sniffin' Sticks smell test in different age groups. METHODS This was a cross-sectional study, conducted at Otorhinolaryngology outpatient clinic of Universiti Kebangsaan Malaysia Medical Centre, Secondary Science School, and Children Learning Centre in Kuala Lumpur, Malaysia, from August 2019 until December 2021. RESULTS In 450 healthy participants, the cut-off points of the threshold discrimination identification (TDI) scores at the 10th percentile for olfactory abilities were 19 in children, 30.1 in adolescents, 32.1 in young adults, 31.1 in middle-aged adults, and 28.6 in older adults. The children had significantly lower olfactory abilities, with the Bonferroni post-hoc tests of p

Intractable sneezing is a diagnosis of exclusion and is mostly psychogenic. We reported a case of an 11-year-old girl who presented with uncontrollable bouts of sneezing for three weeks, which did not respond to conventional treatment. She was eventually diagnosed to have psychogenic intractable sneezing, which was triggered by an unfortunate family circumstance. She improved with psychotherapy and was discharged well. Literature review on intractable sneezing showed that patients were predominately female teenagers and mostly recovered after psychotherapy. Multidisciplinary team effort especially with a child psychiatrist is important for the treatment and follow-up of these patients. Imaging should also be routinely performed as some had underlying organic causes that presented as intractable sneezing.

Since the first documented case of pneumonia of unknown origin hailed from Wuhan city, Hubei province, China, back in December 2019, the novel SARS-CoV-2 leading to COVID-19 has swept across the globe afflicted the people in every corner. As of 21 March 2021, the total case number has culminated to over 122 million worldwide, with a mortality rate of 2.2%.1 11 March 2021 marks the first anniversary since WHO declared the COVID-19 outbreak a pandemic. With the vaccine challenges that lie ahead, the light at the end of the tunnel remains elusive. We learnt that the transmission routes are via respiratory droplet, aerosols and by contact that may be indirect, which succinctly impose a remarkably high risk to the head and neck surgeons who often deal with aerosol-generating procedures. In fact, the first doctor who succumbed to COVID-19 in Wuhan was an otolaryngologist.2 The acknowledgement of a heterogeneous spectrum of clinical manifestations of SARS-CoV-2 viral infection, ranging from asymptomatic to severe disease with multiple organ failure, is of paramount importance. Apart from the overall presentation being fever, myalgia and lower respiratory tract symptoms of cough and dyspnoea, extrapulmonary symptomatology of COVID-19 manifested through a variety of ear, nose, throat (ENT) …

BackgroundLaryngopharyngeal reflux symptoms assessed with the reflux symptom index can overlap with non-allergic rhinitis symptoms. This study aims to explore the association between the reflux symptom index and nasal symptoms in non-allergic rhinitis patients.MethodsA cross-sectional study was conducted on consecutive adults with non-allergic rhinitis. The reflux symptom index (score of more than 13 = laryngopharyngeal reflux) and nasal symptoms (categorised as mild (total score of 0–3), moderate (4–7) or severe (8–12)) were assessed.ResultsThe study included 227 participants (aged 58.64 ± 12.39 years, 59.5 per cent female). The reflux symptom index scores increased with total nasal symptom scores (mild vs moderate vs severe, 8.61 ± 6.27 vs 12.94 ± 7.4 vs 16.40 ± 8.10; p < 0.01). Logistic regression indicated that laryngopharyngeal reflux is more likely in patients with severe nose block (odds ratio 5.47 (95 per cent confidence interval = 2.16–13.87); p < 0.01).ConclusionLaryngopharyngeal reflux symptoms are associated with nasal symptom severity, and nasal symptoms should be primarily treated. Those with predominant nose block and laryngopharyngeal reflux symptoms are more likely to have laryngopharyngeal reflux.

Introduction: Juvenile nasopharyngeal angiofibroma (JNA) is a histological benign but locally aggressive vascular tumour which can invade the base of skull. Aim: This is a retrospective study with the aim to examine the outcome of patients with JNA and endoscopic endonasal excision of tumour at a tertiary center in Malaysia. Material and methods: 9 patients were identified from the medical record office from 2015 to 2019. We review the data on patient demographics, clinical presentations, laboratory investigations, intraoperative blood loss and duration of hospital stay. Results and discussion: 8 patients were male, 1 was female. The average age of diagnosis was 15 (range 11 to 29) years. The commonest chief complaint was recurrent epistaxis, followed by nasal obstruction and nasal discharge. Three patients were at stage I, 4 patients at stage II, 1 patient at stage III and 1 patient at stage IV based on Fisch classification. All patients underwent primary endoscopic endonasal excision of tumour with no vascular, ophthalmological or neurological complication. Seven patients had preoperative embolization done. Average operation time was 137 minutes (range 60–360 minutes). Intraoperative blood lost varied from 500 mL to 1300 mL (mean 777.7 mL). All patients were discharged well with no recurrence. Conclusions: The management of JNA can be challenging. The current shift in management favouring endoscopic endonasal excision of JNA reduces postoperative morbidity. It is possible to be applied on all stages of tumour with good success rate.

Pathology of sphenoid sinus is uncommon and may pose a diagnostic challenge in view of its vague symptoms together with its relatively inaccessible location at the skull base. Radiological imaging is of utmost importance in diagnosis. We present an insidious case of a sphenoid sinus cholesterol granuloma.

There are large between- and within-country variations in COVID-19 death rates. Some very low death rate settings such as Eastern Asia, Central Europe, the Balkans and Africa have a common feature of eating large quantities of fermented foods whose intake is associated with the activation of the Nrf2 (Nuclear factor (erythroid-derived 2)-like 2) anti-oxidant transcription factor. There are many Nrf2-interacting nutrients (berberine, curcumin, epigallocatechin gallate, genistein, quercetin, resveratrol, sulforaphane) that all act similarly to reduce insulin resistance, endothelial damage, lung injury and cytokine storm. They also act on the same mechanisms (mTOR: Mammalian target of rapamycin, PPARγ:Peroxisome proliferator-activated receptor, NFκB: Nuclear factor kappa B, ERK: Extracellular signal-regulated kinases and eIF2α:Elongation initiation factor 2α). They may as a result be important in mitigating the severity of COVID-19, acting through the endoplasmic reticulum stress or ACE-Angiotensin-II-AT1R axis (AT1R) pathway. Many Nrf2-interacting nutrients are also interacting with TRPA1 and/or TRPV1. Interestingly, geographical areas with very low COVID-19 mortality are those with the lowest prevalence of obesity (Sub-Saharan Africa and Asia). It is tempting to propose that Nrf2-interacting foods and nutrients can re-balance insulin resistance and have a significant effect on COVID-19 severity. It is therefore possible that the intake of these foods may restore an optimal natural balance for the Nrf2 pathway and may be of interest in the mitigation of COVID-19 severity.

Background Histiocytic system consists of phagocytes and dendritic cells. Both are found in lymph nodes. Usually, this disorder presents with painless cervical lymph node enlargement hence frequently mistaken for lymphoma or tuberculosis. Case presentation Here, we report three pediatric cases: one of Langerhans cell histiocytosis and two of sinus histiocytosis and massive lymphadenopathy with neck mass as initial presentation. The final diagnosis was made with fine needle aspiration cytology, biopsy, and ancillary tests. Conclusion Biopsy and immunohistochemistry studies are recommended for determining subtypes of histiocytosis and further management of patient.

Purpose The allergic phenotype of chronic rhinosinusitis (CRS) and central compartment atopic disease (CCAD) have been described. The CCAD is a radiological phenotype in patients with CRS that presents as a central mucosal disease due to allergy. The subset of patients having chronic rhinosinusitis with nasal polyps (CRSwNP) has not been well characterized. We aim to describe the clinical and radiological characterizations of patients presenting with the allergic phenotype of CRSwNP. Patients and Methods A cross-sectional study at a tertiary hospital was performed. Adult patients diagnosed with CRSwNP who had both allergology and radiological assessments were enrolled. The symptoms of allergic rhinitis, Lund–Kennedy (LK) endoscopic scoring, Lund–Mackay (LM) computed tomography scan of paranasal sinuses (CTPNS) scoring, CCAD features, skin prick test (SPT) and level of specific IgE were assessed. All the patients underwent SPT for house dust mites. Results A total of 38 patients were enrolled. Symptoms, endoscopic and CTPNS scores were higher in the allergy and CCAD groups compared to the nonallergy and nonCCAD groups. The symptom of “need to blow nose” was statistically significant in allergy vs nonallergy (p=0.01) and CCAD vs nonCCAD (p=0.02). There were significant differences in the endoscopic scores in both allergy and CCAD (allergy vs nonallergy, p=0.01; CCAD vs nonCCAD, p=0.03), and CT scores in both allergy and CCAD (allergy vs nonallergy, p=0.02; CCAD vs nonCCAD, p=0.02). All patients with CCAD have worse scoring than nonCCAD (LK score, p=0.03; LM score, p=0.02). Patients with allergy have more polypoidal involvement of the middle turbinates (left middle turbinate, p=0.141; right middle turbinate, p=0.074) and CCAD (left middle turbinate, p=0.017; right middle turbinate, p=0.009) than nonallergy and nonCCAD patients. Conclusion Allergic phenotype of CRSwNP has a worse clinical and radiological disease burden. Optimal treatment of allergy is essential for a better outcome.

Breast cancer metastases to the base of the skull with concomitant infiltration into the paranasal sinuses and nasopharynx are exceptionally rare with only small numbers of reported literatures. Greenberg et al. in 1981 described five clinical syndromes with regards to the base of skull metastases and the clinical presentation of each syndrome related to its anatomical location. Often, metastases to the base of the skull remain asymptomatic until the lesion has increased to a considerable size causing bony destruction and impingement to the surrounding structures. When involving the paranasal sinuses or nasopharynx, the most common presenting symptoms mimic those of rhinosinusitis and, hence, may delay the accurate diagnosis. We are reporting a case of base of skull metastasis from breast carcinoma, 23 years after the primary diagnosis. To the best of our knowledge, our case is the first case to report latent metastasis of more than 20 years.

Objective: The purpose of this study is to review the correlation of spontaneous cerebrospinal fluid rhinorrhoea (CSFR) and Body Mass Index (BMI) and describe the demographics, the surgical techniques and outcomes. Materials and methods: We performed a retrospective review of clinical data of twenty patients diagnosed with spontaneous CSFR and treated at the Malaysian National University Medical Centre from 1997 to 2015. Result and Discussion: A total of 20 patients were selected in this research (19 females,1male). The mean age was 45.5 years with nineteen females and one male patient. The mean BMI was 33.1kg/m2.Majority of patients with spontaneous leaks are females in their forties. The bath plug technique, onlay of middle turbinate grafts, nasoseptal flaps and mucoperiosteal grafts techniques were used and three patients reported recurrences. Conclusion: Spontaneous CSFR is more common in women in their 40s with BMI>25. The most common sites of leaks are the cribriform plate followed by the sphenoid sinus. Spontaneous CSFR cases are strongly related with increased BMI. Bangladesh Journal of Medical Science Vol.18(2) 2019 p.322-328

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.

Anterior ethmoidal artery (AEA) is at risk of injury in endoscopic sinus surgery due to its location. The aim of this review was to assess the anatomical variations of AEA and their significance. A literature search was performed on PUBMED, SCOPUS AND EMBASE. The following keywords were used: ethmoidal artery; anterior ethmoidal artery; anterior ethmoidal canal; ethmoid sinus; ethmoid roof; skull base. The search was conducted over a period of 6 months between October 2016 and April 2017. 105 articles were retrieved. 76 articles which were either case reports or unrelated topics were excluded. Out of the 29 full text articles retrieved, 16 articles were selected; 3 were cadaveric dissection, 5 combined cadaveric dissection and computed tomography (CT) and the rest were of CT studies. All studies were of level III evidence and a total of 1985 arteries were studied. Its position at the skull base was influenced by the presence of supraorbital ethmoid cell (SOEC) and length of the lateral lamella of cribriform plate (LLCP). Inter population morphological variations contribute to the anatomical variations. The average diameter of AEA was 0.80 mm and the intranasal length was 5.82 mm. 79.2% was found between the second and third lamellae, 12.0% in the third lamella, 6% posterior to third lamella and 1.2% in the second lamella. Extra precaution should be taken in the presence of a well-pneumatized SOEC and a long LLCP as AEA tends to run freely below skull base.

Background The orbital floor is considered as an important intraoperative reference point in endoscopic sinonasal surgery. The aim of this review is to evaluate its reliability and usefulness as a surgical landmark in endoscopic endonasal surgery. Methods A literature search was performed on electronic databases, namely PUBMED. The following keywords were used either individually or in combination: orbital floor; maxillary sinus roof; endoscopic skull base surgery; endoscopic sinus surgery. Studies that used orbital floor as a landmark for endoscopic endonasal surgery were included in the analysis. In addition, relevant articles were identified from the references of articles that had been retrieved. The search was conducted over a period of 6 months between 1st June 2017 and 16th December 2017. Results One thousand seven hundred forty-three articles were retrieved from the electronic databases. Only 5 articles that met the review criteria were selected. Five studies of the orbital floor (or the maxillary sinus roof) were reviewed, one was a cadaveric study while another 4 were computed tomographic study of the paranasal sinuses. All studies were of level III evidence and consists of a total number of 948 nostrils. All studies showed the orbital floor was below the anterior skull base irrespective of the populations. The orbital floor serves as a guide for safe entry into posterior ethmoids and sphenoid sinus. Conclusions The orbital floor is a reliable and useful surgical landmark in endoscopic endonasal surgery. In revision cases or advanced disease, the normal landmarks can be distorted or absent and the orbital floor serves as a reference point for surgeons to avoid any unintentional injury to the skull base, the internal carotid artery and other critical structures.

Three dimensional (3D) models mimic the features of native tissue environment. Thus, morphology and signalling of cells from 3D culture are often more physiological than routine two dimensional (2D) cell culture. It is also known that the cell-secreted products have paracrine effect on other cells growth. In this experimental study, we optimised the nasal fibroblast culture on a 3D cell culture system and studied the effects of secretome from the 3D culture (3DCM) onto fibroblast growth and cytoprotection. Nasal fibroblast was isolated from human nasal turbinates. The suitable microcarrier was selected by culturing the fibroblasts in passage 3 on various types PolyGEM™ polystyrene microcarriers. Then, the cells were cultured on selected microcarrier using a 3D culture system and the conditioned medium (CM) was collected. 3DCM were supplemented to fibroblasts to study for attachment, proliferation, and cytoprotective effects against cytotoxicity of Centella asiatica. Bicinchonic Acid Assay (BCA) was performed to quantify protein amount in CMs. Sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) was performed for preliminary profiling and comparison of 2DCM and 3DCM protein profile. Our study showed that the 3DCM did not significantly enhance cell attachment and proliferation. The secretome of both 2DCM and 3DCM found to have significant cytoprotective effect onto nasal fibroblast against cytotoxicity of C.asiatica extract. 3DCM had higher protein concentration than 2DCM. SDS-PAGE showed three exclusive proteins in 3DCM and four exclusive proteins in 2DCM. Future study should be conducted on utility of nasal fibroblast secretome on cytoprotection against harmful agents in environment and cytotoxicity of natural products.

Background Epiphora secondary to nasolacrimal duct obstruction is common in the pediatric age group. The mainstay treatment among these young patients has been conservative. Once epiphora becomes recalcitrant, however, an external or an endonasal approach is considered. Objective Endoscopic dacryocystorhinostomy (EDCR) entails creating an opening from the lacrimal sac directly into the nasal cavity to counteract nasolacrimal duct obstruction. We reviewed the literature to determine the effectiveness and the safety of primary EDCR to treat pediatric nasolacrimal duct obstruction. Method A literature search was conducted by using a number of medical literature data bases for the period from 1995 to 2016. The following search words were used either individually or in combination: epiphora, nasolacrimal duct obstruction, endoscopic dacryocystorhinostomy, powered endoscopic dacryocystorhinostomy, laser-assisted endoscopic dacryocystorhinostomy, children, congenital, acquired, presaccal obstruction, and postsaccal obstruction. In addition, a few articles were identified based on the experience and information provided by the senior authors (B.A., S.H., D.Y.W.). The search was conducted over a 1-month period (January 2017). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews of Interventions were followed when possible. Results Only 10 original clinical research articles were selected based on our objectives and selection criteria. All the studies were at level of evidence III: nonrandomized and noncomparative prospective or retrospective case series. Altogether, 313 patients with ages that ranged from 4 months to 18 years were enrolled. A total of 352 EDCRs were performed that were either single sided (n = 313) or bilateral (n = 39). The most common causes of the obstruction were classified as congenital, followed by idiopathic, and then acquired. A meta-analysis was not performed because of the heterogeneity of the patient groups and variability of the methods used to measure outcomes. Conclusion Analysis of the results indicated that EDCR was an effective, safe therapeutic approach to treating nasolacrimal duct obstruction in pediatric patients. It should be considered as an alternative procedure to external dacryocystorhinostomy after a failed conservative treatment.

Background: Allergic rhinitis is a known health problem worldwide. Objective: The aim of the study was to determine the association between breastfeeding and serum IgE level as well as its impact on quality of life in children with allergic rhinitis. Methodology: A cross sectional comparative study was done among pediatric patients aged 6-12 who have allergic rhinitis with evidence of positive skin prick test (SPT), for 30 specifically selected patients each for breastfed and non-breast-fed. For each patient, serum IgE was taken and interviewed using the modified allergy questionnaire by validated Sher Allergy Specialists questionnaire (Florida) and Rhinoconjuntivitis Quality of Life Questionnaires (RQLQ) by Juniper. Statistical analysis was performed using SPSS 13.0. The significant association was analyzed using Pearson’s chi-square and Mann-Whitney U tests. Results: There was no significant difference ( p = 0.688) with regards to serum IgE level between breastfed and non-breast-fed children. However, children who were breastfed have a better mean of quality of life (mean=1.1679) than non-breast-fed (mean=1.5274). Conclusion : Our study showed that there is no association between breastfeeding and serum IgE level. Nevertheless, the quality of life is better in breastfed children. A larger sample and longer duration of study are required to substantiate these findings. Bangladesh Journal of Medical Science Vol.16(4) 2017 p.530-534

For teaching and learning Malay language grammar, there are many types of online assessment tools and applications have been developed in Malaysia. One such application is Quizizz, a game-based online quiz that facilitates teaching and learning. The purpose of this research is to measure the effectiveness of Quizizz application to teach and learn Malay grammar. We have used descriptive questionnaire research design, and chosen 130 students from Tamil schools by following the simple random sampling strategy. We have explored the effectiveness of Quizizz application as a formative quizzing tool for teaching and learning Malay grammar in year-four Tamil school students from 15 Tamil schools in Manjung district. The results showed that it was imperative to use Quizizz as a formative assessment tool to learn and teach Malay grammar to Tamil students. Students also responded positively to the use of Quizizz in the classroom through survey questionnaire results. At the end, we conclude that it is important for teachers to consider using fun and entertainment technology quizzing tools to teach Malay grammar. Keywords: Malay grammar, Quizizz, Self-assessment, Teaching and learning

A 39-year-old man presented with bilateral nasal obstruction for 4 months and associated with hyposmia and foul-smelling nasal discharge. Nasal endoscopy showed irregular mucosa of the nasal cavity with easily bleeding. Nasal biopsy reported as extranodal Natural Killer/T cell lymphoma, nasal type. In-situ hybridisation for Epstein-Barr encoding region was positive. He was treated with six cycles of gemcitabine, oxaliplatin and L-asparaginase and peripheral blood stem cell transplant. After the treatment, he was asymptomatic until 9 months where he had splenic abscess and undergone splenectomy. He was asymptomatic of the disease for 2 years.

Primary sinonasal nasopharyngeal-type undifferentiated carcinoma (PSNPC) is a rare variant of the sinonasal undifferentiated carcinoma (SNUC). The histological classification has implications on its management. We report a case of a 32 year old lady who presented with progressive nasal obstruction due to a sinonasal tumour. Endoscopic excision was performed and examination confirmed PSNPC with positive Epstein Barr virus in-situ hybridisation. Identification and recognition of PSNPC as a separate clinicopathological entity from SNUC is important as it dictates the management of this rare variant. Immunohistochemical analysis is invaluable in this endeavor.