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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.

Eosinophil-type nasal polyp (NP) is common in Western population. This aim of this study was to determine the histology type of NP among different Malaysian ethnic groups. A total of 122 chronic rhinosinusitis with nasal polyposis (CRSwNP) patients were retrospectively enrolled and demographic data was recorded. The histological slides were retrieved. The number of eosinophils and non-eosinophils were counted and average number of inflammatory cells for each high power field was calculated. Eosinophil-predominant was seen in 32.8% of patients and 67.2% was non-eosinophil-predominant. Phenotypes of NP significantly showed an association with ethnicity (x² = 8.322; p < 0.05). A total of 78.9% of Chinese nasal polyps showed non-eosinophil predominant, while Malay and Indian nasal polyps revealed 71.9% and 40.7% of non-eosinophilic phenotype, respectively. Our study showed that Malaysian population had a non-eosinophilic phenotype of nasal polyps. There was a significant association in Malaysian ethnicity with the highest percentage in Chinese population.

Esthesioneuroblastoma is a rare malignant neoplasm of oflactory neuroepithelium and usually located at the olfactory cleft at superior nasal cavity. Ectopic localization of esthesioneuroblastoma is even rarer and usually posed with a diagnostic dilemma and delay in the diagnosis and management, We report a rare case of ectopic esthesioneuroblastoma of the sphenoclivus with the presentation of intermittent unilateral epistaxis, intermittent intractable headache without anosmia. Nasal endoscopy findings showed a pulsatile mass at the anterior face of the sphenoid sinus with extension posteriorly towards the clivus region and occupying the floor of the sphenoid sinus. Endonasal transclival endoscopic excision of tumour was performed which involved otorhinolaryngology surgeon and neurosurgeon with intraoperative navigation imaging and frozen section. The histopathological findings was esthesioneuroblastoma. Due to its rarity and unusual presentation, the diagnosis of ectopic esthesioneuroblastoma is difficult and can be misdiagnosed with the other type of malignancy. Therefore, the histopathological result is important in confirming the type of tumour and can lead to the next step of management.

BACKGROUND Allergen specific immunoglobulin can be present in the nasal mucosa of patients with non-allergic rhinitis (NAR). This condition is defined as local allergic rhinitis. However, the reported presence of nasal specific immunoglobulin E (nspIgE) among NAR is variable. The aim of this review was to summarize the studies which reported the presence of nspIgE among patients diagnosed as NAR. METHODS Embase (1947- ) and Medline (1946-) were searched until 6th June 2017. A search strategy was utilized to identify studies on nspIgE among patients with NAR. The target population was patients with symptoms of rhinitis, but negative systemic allergen sensitization. Studies with original data on detectable nspIgE among the NAR population were included. Meta-analysis of single proportions as a weighted probability %(95%CI) was performed. Heterogeneity was explored amongst studies. RESULTS A search strategy returned 2286 studies and 21 were included. These studies involved 648 participants with NAR. NspIgE was detected using either; 1. nasal secretions, 2. epithelial mucosa sampling, 3. tissue biopsies or 4. In-situ tests. Metaanalysis was performed on studies with nasal secretions. The weighted proportion of detectable nspIgE in nasal secretions within patients with NAR was 10.2 (7.4-13.4) %. Population definitions partly explained variability. Detection of nspIgE was lower in patients without a history suggestive of allergy compared to those with a positive allergic history (0 (0-3.1) % v 19.8 (14.5-25.6) %, p

Amniotic membrane has the potential to be used as scaffold in various tissue engineering applications. However, increasing its biostability at the same time maintaining its biocompatibility is important to enhance its usage as a scaffold. This studied characteristics genipin-crosslinked amniotic membrane as a bioscaffold. Redundant human amniotic membranes (HAM) divided into native (nAM), decellularized (dAM) and genipin-crosslinked (clAM) groups. The dAM and clAM group were decellularized using thermolysin (TL) and sodium hydroxide (NaOH) solution. Next, clAM group was crosslinked with 0.5% and 1.0% (w/v) genipin. The HAM was then studied for in vitro degradation, percentage of swelling, optical clarity, ultrastructure and mechanical strength. Meanwhile, fibroblasts isolated from nasal turbinates were then seeded onto nAM, dAM and clAM for biocompatibility studies. clAM had the slowest degradation rate and were still morphologically intact after 30 days of incubation in 0.01% collagenase type 1 solution. The dAM had a significantly highest percentage of swelling than other groups (p 0.05). Besides, the dAM retained the collagen content at similar level of nAM. Although the dAM had highest mechanical strength compared to the rest of the groups, the differences were statistically insignificant. Cell attachment on dAM and 0.5% clAM was higher compared to that on nAM and 1.0% clAM. In conclusion, clAM have better biostability and biocompatibility compared to the nAM and dAM. Together with other suitable characteristics of the clAM such as percentage of swelling, structural integrity and ECM content, clAM is suitable as scaffold for various tissue engineering applications.

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. 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. 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

Nasal irrigation is an effective and cheap method in managing post sinonasal surgery patients. It works by improving ciliary clearance and performing mechanical debridement of the thick crust, decreasing mucosal edema and reducing the inflammatory mediators. Presence of nasal irrigation bottle contamination and its effect on patients have been studied. The aim of this study is to prospectively identify the risk of contamination in the nasal irrigation bottle, fluid from the bottle and to correlate with endoscopic findings from the patients who had underwent sinonasal surgery. Swabs will be taken from the nasal irrigation bottle and patient’s middle meatus before the surgery and at each post surgery visits (2 and 4 weeks). Patients will be advised to irrigate their nose three times per day post sinonasal surgery. During endoscopic examination of the patient’s nasal cavity at 2 and 4 weeks, any evidence of infection will be noted and documented. Additionally, a swab of fluid irrigated from the nasal cavity collected during the clinic follow-ups will also be taken. The specimens will be sent to the Microbiology laboratory for standard culture and sensitivity test. A total of 27 patients completed the study and were divided into case (n = 15) and control (n = 12) groups. The CFU (colony-forming unit) value of the bacteria cultured from the nasal cavity and the nasal irrigation bottle was statistically significantly (P = 0.00) increased from the baseline to the second week follow-up in both groups but not from the second week to the fourth week follow-up. The majority of the swabs from the nasal cavity of the patients and the nasal irrigation bottles were positively cultured for Pseudomonas sp. group. Other groups of bacteria that were cultured were Enterobacter sp., Coagulase Negative Staphylococcus (CONS) and Klebsiella sp. Endoscopically, there was no clinical evidence of infection found in the nasal cavity of the patients. The nasal irrigation bottle that was used in the post sinonasal surgery treatment and for alleviation of symptoms of sinonasal diseases was found to have bacterial contamination from the swabs taken from the bottle. However, despite this finding there was not clinical evidence of infection noted from the nasal endoscopic examination. A simple and effective method of cleaning the bottle would be helpful to reduce the bacterial contamination for this useful treatment method.

Background: The aim of this prospective study is to evaluate whether changes in endoscopy score correlate with changes in quality of life (QOL) in nasal polyposis (NP) patients after optimal medical therapy. Methodology: An interventional clinical trial study involving fifty five patients with grade I and II NP was conducted. Patients were initially treated with a single dose oral prednisolone 25 mg for 2 weeks, Macrolide 250 mg daily for the first 3 months and long-term intranasal steroids. All patients were followed up and evaluated subjectively by Rhinosinusitis Disability Index question- naire and objectively by endonasal endoscopy between December 2011 to October 2013. Results: At baseline, patients showed significantly bad QOL scores on all domains. At 3 months, a significant improvement in all impaired QOL domains and reduction of the nasal polyp size were demonstrated compared to baseline. At 6 and 12 months, no significant improvement between QOL scores and nasal polyp size was observed. Conclusion: Optimal medical treatments improve both the QOL and nasal polyp size in grade I and II NP patients. However, the changes in endoscopy scores explain a part of the improvement in QOL outcomes as the latter are multidimensional constructs.

The Schneiderian membrane gives rise to 3 morphologically distinct tumours: septal, inverted (IP) and oncocytic schneiderian papillomas (OSP). OSP, although, almost parallel to IP, still have its own distinct features in the incidence, location, clinical presentation and histological examination. Despite the differences, the standard treatment is still surgical removal of the tumour. External approach is preferred but in view of advanced endoscopic technique, it is feasible to remove the tumour endoscopically with carefully selected tumour presentation. DOI: http://dx.doi.org/10.3329/bjo.v18i2.12033 Bangladesh J Otorhinolaryngol 2012; 18(2): 215-218

Objective:We report an extremely rare case of metachronous inflammatory myofibroblastic tumour in the temporal bone.Method:Case report and review of the world literature on metachronous inflammatory myofibroblastic tumour.Results:Inflammatory myofibroblastic tumour in the temporal bone is rare, and metachronous inflammatory myofibroblastic tumour in the temporal bone has never been reported in the English medical literature. We report a case of inflammatory myofibroblastic tumour in the right temporal bone in a 27-year-old woman presenting with right-sided otalgia and progressive hearing loss. A metachronous lesion was discovered in the left temporal bone one year later. The patient underwent surgical excision of the tumour via canal wall down mastoidectomy for both lesions. Long term steroids were prescribed after both surgical procedures. At follow up three years after the last procedure, the patient remained free of disease.Conclusion:To the best of our knowledge, this is the first reported case of metachronous inflammatory myofibroblastic tumour in the temporal bone.

A prospective single blinded interventional study was held in Otorhinolaryngology Clinic, Universiti Kebangsaan Malaysia Medical Centre in August 2010 until November 2012 to evaluate the functional outcome of septorhinoplasty objectively and subjectively. Objective assessment was done using rhinomanometry and subjective assessment using Nasal Obstruction Symptoms Evaluation (NOSE) scale and Health-Related Quality of Life Questionnaires (HRQOL) in Rhino Surgery. All measurements were taken preoperatively and 3 months postoperatively. A total of 29 patients were enrolled and completed the study. Septorhinoplasty was commonly performed in Malays and Indians and rare amongst Chinese, with age ranged from 18 to 54 years. Majority had no history of trauma. Twisted nose was the most common external nose abnormality followed by crooked and saddle nose. All patients had internal valve insufficiency. There were significant improvement of the total and of all the parameters in the NOSE scale post septorhinoplasty (p 0.05). Significant correlations were noted in the improvement between the two subjective assessments (NOSE scale and HRQOL score). However, there was no significant correlation in the improvement between the subjective (NOSE scale and HRQOL score) with objective (rhinomanometry score) assessments. Septorhinoplasty improves the nasal airflow and quality of life of patients with nasal obstruction.

A 40-year-old woman presented with diplopia and left VI nerve palsy. After investigations, diagnosis of a meningioma in the parasellar-prepontine region was considered. Following angiography and embolization, near-total excision of the tumour attached to abducens nerve was performed. Histological examination was consistent with the diagnosis of schwannoma. This is the thirteenth case report of a schwannoma of cranial nerve VI and the first such case where embolization of feeding tumour vessels was performed.

Objective:This study investigated improvements in quality of life associated with eight weeks of montelukast and/or intranasal steroid treatment for moderate to severe allergic rhinitis.Methods:A single-centre, prospective, randomised, double-blind, placebo-controlled study was carried out. Assessments were made using the Rhinoconjunctivitis Quality of Life Questionnaire and symptom scales.Results:A total of 128 patients (aged 13–51 years) were randomly assigned to one of two groups. In the montelukast group, patients were treated with montelukast tablets and fluticasone propionate nasal spray (n = 64). In the placebo group, treatment comprised a placebo and fluticasone propionate. The results showed significant improvements in symptom scores and quality of life scores for both groups after one month and two months of treatment, compared with baseline values; these improvements were significantly greater for the montelukast group compared with the placebo group. The mean number of loratadine tablets taken by each patient during the study period was only 0.73 for the montelukast group compared with 9 for the placebo group.Conclusion:The combination of montelukast tablets and fluticasone propionate nasal spray improved symptom control and overall quality of life for moderate to severe allergic rhinitis patients.

Nasal polyposis (NP) has a great impact on quality of life (QOL) and its management involves a combination of medical therapy and surgery. To the authors' knowledge, no publication has extensively examined NP after optimal medical treatment based on subjective evaluations. The aim of this prospective study was designed to evaluate the QOL in NP patients after (1) a short course of oral steroids, (2) initial 3-month course of macrolide, and (3) long-term treatment with intranasal steroids. A total of 55 patients with grades I and II NP were consecutively treated with oral prednisolone at 25 mg in a single dose for 2 weeks, macrolide at 250 mg daily for the first 3 months, and long-term intranasal steroids. Patients were followed up and evaluated at baseline and 3, 6, and 12 months for QOL measure. At baseline, patients with grade I and grade II NP showed significantly worse QOL scores on all Rhinosinusitis Disability Index domains, particularly for physical function (4.59 ± 1.41) and were significantly higher in social function (3.16 ± 1.17). At 3, 6, and 12 months of treatment, patients showed a significant improvement in all impaired QOL domains compared with baseline after optimal medical therapy (p < 0.05). These results suggest that the optimal medical treatment to improve QOL incorporates medical polypectomy with a short course of oral steroids in addition to macrolide and this can be maintained by long-term intranasal steroid therapy.

The purpose of this retrospective joint rhino-neurosurgical study from January 1998 until September 2009 is to document the demographic data, clinical presentations, radiological findings, approaches and incidence of residual tumour. Forty-seven patients with pituitary adenoma underwent trans-sphenoidal hypophysectomy of which 25 patients with complete medical and radiological data were included in the study. The medical and radiological data were analyzed. There were 12 males and 13 females with age ranging from 17 to 76 years old (mean 49.2). Fourteen of the patients were Chinese, eight Malays and three Indians. Twelve of the patients had functioning tumour of which five each presented with acromegaly and Cushing disease respectively and two with amenorrhoea. The rest of 13 patients had non functioning tumour presenting with visual disturbances. Sixteen of the patients had pituitary macroadenomas and the rest 9 microadenomas. Eighteen patients had undergone transcollumellar trans-sphenoidal hypophysectomy and the rest 7 patients had undergone transnasal transsphenoidal hypophysectomy. About 68.8% of pituitary macroadenomas had residual tumour, compared to only 22.2% of patient with pituitary microadenomas. Radiologically, about 45.5% of residual macroadenoma had suprasellar extension and the majority had spread to suprasellar cistern and carvenous sinus (54.5%). About 16.6% of patients had undergone post operative radiotherapy. In conclusion, this study showed that patient with pituitary macroadenomas had higher incidence of residual tumour compared to pituitary microadenomas.

Objective: To describe our experience in managing two cases of primary malignant parotid lymphoma. Methods: Design: Case Report Setting: Tertiary University Referral Center Patients: Two Results: Both patients underwent superficial parotidectomy. Despite recurrence in one, the disease was controlled with conservative management. However, the disease was more aggressive in the other, requiring additional chemo-radiotherapy. Conclusion: Malignant parotid lymphoma may present with varying stages, grades and clinical courses, requiring different management approaches. The treatment options are based on grading and staging at diagnosis and should be implemented depending on individual case. Keywords: Parotid neoplasms, malignant lymphoma

Cutaneous metastasis of hepatocellular carcinoma (HCC) is very rare, accounting for less than 0.8% of all known cutaneous metastases and occurring in 2.7-3.4% of HCCs. With less than 50 such cases reported worldwide, most of which were diagnosed histologically on excised lesions, it can only be expected that diagnosis made on cytological features alone would be challenging. We report a case of cutaneous metastasis of HCC diagnosed based on cytological features and confirmed by Hep Par 1 immunopositivity of the cell block material. An 81-year-old man, who was known to have unresectable HCC, presented with a 1-month history of painless, left nasal alae mass. The mass measured 1.5 cm in diameter, and was multilobulated with a central necrosis. Fine needle aspiration of the mass was done. Smears were cellular, comprising of malignant cells in loose clusters and aggregates as well as singly dispersed. The malignant cells displayed moderate nuclear pleomorphism, occasional prominent nucleoli, and intranuclear pseudoinclusion. Cell block material demonstrated the trabeculae pattern of the malignant cells and Hep Par 1 immunopositivity. The final diagnosis of a metastatic cutaneous HCC was made. In conclusion, cutaneous HCC metastasis is rare and should be considered in the differential diagnosis in patients with a history of HCC presenting with suspicious skin lesion. In the right clinical setting, a confident diagnosis can be made in such cases by using the fine needle aspiration technique aided with immunopositivity for Hep Par 1 antibody of the aspirated material.

This study aimed to evaluate the consistency between tertiary learners’ writing self-efficacy and writing performance evaluation in academic writing in order to understand the tertiary students’ self-efficacy phenomena in learning to write. Two measurements were analysed and compared namely the learners’ writing self-efficacy scales and learners’ writing performance. Basically, it is a case study where 33 UPM students participated in the research for four months. In this study, the learners’ writing self-efficacy was assessed based on the writing self-efficacy (WSE) scale adapted from Bottomley, Henk & Melnick (1997), while, the document analysis was based on the students’ writing performance throughout the four months. Overall, this study did not mainly based on the score of WSE scales only but also looked from the angle of the students’ writing performance by looking at writing skills in detail namely content, organization, grammar, vocabulary and mechanic of writing. Here, the analysis of the essay and rating was done from the perspective of Jacobs, Zinkgraf, Wormuth, Hartfiel, & Hughey (1981) and adapted by Hedgcock and Lefkowitz (1992). In order to plot the consistency and trend of the two measurements (WSE and writing skills), ratio and Chi-square analysis were carried out using SPSS program. Findings showed that the distribution of writing skills performance vary depending on the self-efficacy level (i.e. high, average and low self-efficacy level).

Introduction: Angiomyolipoma (AML), a benign mesenchymal tumor that commonly arises from the kidney, may be associated with tuberous sclerosis complex and perivascular epithelioid cell tumors (PEComas). Nasal angiomyolipoma is very rare and usually occurs in elderly individuals with epistaxis and nasal obstruction. Case Report: We report a rare case of nasal angiomyolipoma in a young male. To the best of our knowledge, this is the first documented case of angiomyolipoma originating from the posterior end of the inferior turbinate, clinically mimicking juvenile nasopharyngeal angiofibroma (JNA). The tumor was removed completely via coblator-assisted endoscopic sinus surgery. The patient was asymptomatic at a 2-year follow-up. Conclusion: Nasal AML located in the posterior nasal cavity in a male patient can mimic the presentation of JNA. A computed tomography scan of the paranasal sinuses played an important role in differentiating nasal AML from JNA. The coblator-assisted endoscopic technique is useful in controlling intraoperative hemostasis in the removal of a suspicious vascular tumor.