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Ceruminous adenoma is a rare and benign tumor of the external auditory canal and present with a nonspecific symptom. Biopsy with histopathology examination is required to establish the diagnosis. Wide local excision of tumour shows favourable outcome with a low recurrence rate. Here, we present a case of ceruminous adenoma masquerading as a furunculosis., Competing Interests: Competing InterestsThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© Association of Otolaryngologists of India 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Aim: Nasopharyngeal carcinoma (NPC) is prevalent in certain regions, particularly Southeast Asia and Southern China. In Malaysia, it is notably frequent among the Bidayuh community. This study presents a comprehensive review of NPC cases diagnosed and treated at Sarawak General Hospital from 2010 to 2020., Method: A retrospective data collection was conducted using the clinical records of patients who were histopathologically diagnosed with NPC at the Otolaryngology-Head & Neck Clinic and the Radiotherapy & Oncology Clinic at Sarawak General Hospital., Result: The study comprised a total of 892 patients from 2010 to 2020. Males outnumbered females 3-to-1, with a mean age of 51 years (standard deviation: 13.9). The largest groups of patients were the Iban (34%) and the Bidayuh (21%), followed by the Chinese (19%) and the Malay (15%). The Bidayuh had the highest incidence rate with 81 cases per 100,000. Only 10% of the study population had a family history of NPC. The most common presentation was a neck lump (64.5%). Distant metastasis was discovered in 20% of patients. 82% of the cases were stage 3 or 4 at the time of presentation. The histological types of the 892 cases were mainly undifferentiated carcinoma (73%). Eighty-six patients developed recurrence, with 83% experiencing local recurrence, 10% developing distant metastasis, and 7% developing regional recurrence. Treatment for recurrence included nasopharyngectomy, neck dissection, and chemotherapy., Conclusion: The study highlights a significant incidence of NPC among the Bidayuh. Emphasis on screening and early detection is crucial for better outcomes, with lifelong follow-up recommended., Competing Interests: Declarations Competing interests The authors have no relevant financial or non-financial interests to disclose., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Sinonasal carcinoma, a rare and challenging malignancy, originating in the nasal cavity and paranasal sinuses, poses diagnostic and management complexities. This 8-year retrospective analysis at Sarawak General Hospital aims to elucidate demographic trends, histopathological entities, and management outcomes, shedding light on this multifaceted malignancy. Emphasizing the significance of accurate histopathological classification, the study explores the impact on prognostication and treatment strategies. Spanning 2013 to 2021, the study involved 54 patients with sinonasal malignancies. Demographic, clinical, and histopathological details were examined, adhered to the AJCC staging criteria. Analysis involved demographic distributions, tumour characteristics, treatment modalities, and instances of treatment failure. Statistical analysis was done using SPSS version 29.02. The cohort, predominantly male (57.4%) and of Iban ethnicity (44.4%), with a mean age of 52.8 years, exhibited diverse histopathologies, with squamous cell carcinoma as the most common (38.9%). Epistaxis and nasal blockage were common clinical presentations. Advanced stages (III and IV) were prevalent, with the nasal cavity as the primary site. Surgical interventions, mainly endoscopic endonasal excision, were complemented by adjuvant therapies. Complications occurred in 24% of cases. The study highlights a male predilection, occupational risk factors, and a significant association between tobacco smoking and sinonasal cancers. Surgical interventions predominantly utilized the endoscopic approach. Despite a mean survival of 46.6 months, treatment failure occurred in 29.6% of cases, with recurrence and metastasis. Histopathological analysis revealed comparable 5-year disease survival rates between squamous and non-squamous histologies. Treatment failure was significantly associated with the mode of surgery, with open surgery showing a lower incidence. However, nodal status, histopathology types, T staging, and overall staging did display positive associations with treatment failure. This 8-year review provides comprehensive insights into sinonasal carcinoma, addressing demographic, clinical, and histopathological dimensions. The study underlines the complexity of managing this challenging malignancy, emphasizing the need for a holistic approach to patient care. The findings contribute to the understanding of sinonasal carcinoma, guiding clinical decision-making and fostering further research., Competing Interests: Competing InterestsThe are no competing interest or funding from any side regarding the above article., (© Association of Otolaryngologists of India 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background: Fish bone ingestion is commonly encountered in emergency department. It poses a diagnostic and therapeutic challenge particularly when it migrates extraluminally, necessitating a comprehensive and multidisciplinary approach for successful management., Case Presentation: Here we reported four cases of extraluminal fish bone. The first patient was a 68-year-old Chinese man who had odynophagia shortly after a meal involving fish. The second was a 50-year-old Iban man who reported a sharp throat pain after consuming fish 1 day prior. The third patient was a 55-year-old Malay woman who developed throat pain and odynophagia after consuming fish 1 day earlier. The fourth patient, a 70 year-old Iban man, presented late with odynophagia, neck pain, swelling, and fever 1 week after fish bone ingestion. These unintentional fish bone ingestions faced challenges and required repeat computed tomography scans using multiplanar reconstruction in guiding the surgical removal of the fish bone., Conclusion: We underscore the significance of multiplanar reconstruction in pinpointing the fish bone's location, demonstrating the migratory route, and devising an accurate surgical plan., (© 2024. The Author(s).)

Ingested fish bone is a common otorhinolaryngology emergency in Malaysia. Fish bone is commonly impacted in the oropharynx for young patients and oesophagus for elderly patients. Rarely, a fish bone migrated extraluminal and require surgical exploration. We report a five cases of fish bone which involved extraluminal migration, and needed repeat CT scans and various types of surgical exploration., Competing Interests: Ethical ApprovalThe authors declare that they are compliant with standards, no funding involved, no conflict of interest and ethical approval has been obtained., (© Association of Otolaryngologists of India 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Unilateral nasal obstruction with purulent nasal discharge is one of the presentations for sinonasal melioidosis. However, it may mimic nasal NK/T cell lymphoma. Both causing tissue destruction involving nasal septum, lateral nasal wall and palate. Here, we report a case of disseminated melioidosis involving sinonasal mimicking nasal lymphoma in a 32-year-old immunocompetent lady. She presented with prolonged fever, unilateral nasal blockage, painful facial swelling and knee pain. Clinical findings revealed extensive necrotic tissue and crusting involving right lateral wall of nasal cavity. Tissue and blood culture and sensitivity (C + S) grew Burkholderia pseudomallei . Recovery was complete after surgery and antibiotics., Competing Interests: Conflict of interestThe authors declare that they have no known competing financial interests or personal relationships that could influence the work of reporting the case., (© Association of Otolaryngologists of India 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

We report a rare case of localized anterior clinoid mucocele (ACM) with acute visual loss and a literature review of the endoscopic endonasal surgery. We advocate that endoscopic endonasal approach is the best choice. To our knowledge there a limited report on localized ACM that treated via endoscopic endonasal approach., Competing Interests: Conflict of InterestAuthors declare that they have no conflict of interest., (© Association of Otolaryngologists of India 2022. Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background : A spontaneous cerebrospinal leak from Sternberg's canal with meningoencephalocele is a very rare clinical entity. Endoscopic repair of the defect is challenging and crucial in identifying the defect. The aim of this case report is to highlight the presence and management with endoscopic surgery in repairing Sternberg canal. Case : 40-year-old woman presents with spontaneous CSF rhinorrhea with no predisposing factors. CT imaging and MRI showed osteodural defect in the lateral recess of sphenoid with meningoencephalocoele lateral to the foramen rotundum. Endoscopic transethmoidal - transphenoidal - transpterygoid approach was used to repair the defect, and patient is well post-operative with least complication from the intervention surgery. Conclusion : Endoscopic approach proved to be the best and safest method in localizing the defect and closure of the leak. Angled scopes and image guided system were used to identify the precise location of the leak., Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03347-z., Competing Interests: Competing InterestsThe authors declare that they have no competing interests., (© Association of Otolaryngologists of India 2022, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Pharyngeal lipoma of the upper aero-digestive system is extremely rare. It is typically benign, slow growing and symptoms would depend on its size and location. Surgical intervention is often needed especially for large tumour with impending airway obstruction. Here we present a case of potentially life threatening presentation of pharyngeal lipoma., (© Association of Otolaryngologists of India 2021.)

Temporal bone squamous cell carcinoma (TBSCC) is a rare head and neck malignancy with the incidence 0.8 -1.0 cases in 1 million population. We are reporting a case series on the TBSCC cases that were operated on at Sarawak General Hospital, Malaysia. Ten patients were identified and collected with the presentation and type of surgery performed. It has been challenging for us to manage with recorded 2 years surviving in 6 out of 10 patients operated within this period. An adequate management with proper surgical resection of tumour and radiotherapy can extend the life expectancy for TBSCC patients.

Chordomas are rare and slow-growing locally destructive bone tumors that can develop in the craniospinal axis. It is commonly found in the sacrococcygeal region whereas only 25-35% are found in the clival region. Headache with neurological deficits are the most common clinical presentations. Complete surgical resection either via open or endoscopic endonasal approaches are the main mode of treatment. Here, we report a series of 5 cases of clival chordomas which was managed via endoscopic endonasal approaches in our center. A retrospective analysis of patients who had undergone endoscopic endonasal resection of clival chordoma in Sarawak General Hospital from 2014 to 2018. A total of 5 cases were operated on endoscopically via a combine effort of both the otorhinolaryngology team and the neurosurgical team during the study period from year 2013 to 2018. From our patient, 2 were female and 3 were male patients. The main clinical presentation was headache, squinting of eye and nasopharyngeal fullness. All our patient had endoscopic endonasal debulking of clival tumor done, with average of hospital stay from 9 - 23 days. Pos-operatively, patients were discharged back well. Endoscopic endonasal resection of clival chordomas gives good surgical resection results with low morbidity rates and therefore can be considered as a surgical option in centers where the surgical specialties are available., Competing Interests: Conflict of interestThe authors declare that they have no competing interests.Ethics approvalThe authors declare that they have no competing interests., (© Association of Otolaryngologists of India 2021.)

Caroticocavernous fistulae can occur following transsphenoidal surgery even without evidence of carotid artery injury. A role of vascularized flap reconstruction may be contributory., Competing Interests: The authors of this paper reports no conflicts of interest., (© 2021 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Competing Interests: Intérêts concurrents: Leena Taji, Doneal Thomas, Jane Ip, Yiwen Tang, Angie Yeung et Rebecca Cooper sont des employés salariés du Réseau rénal de l’Ontario (Santé Ontario). Matthew Oliver est propriétaire d’Oliver Medical Management Inc., qui distribue sous licence des logiciels d’analyse pour la gestion de la dialyse et la préparation de rapports. Il a reçu des honoraires à titre de conférencier de Baxter Healthcare et a participé à des comités consultatifs pour Janssen et Amgen. Peter Blake a reçu des honoraires de Baxter Global pour des conférences. Andrew House a reçu des honoraires de Baxter pour des conférences. Phil McFarlane a reçu des honoraires à titre de consultant ou de conférencier d’Amgen, Astra-Zeneca, Bayer, BMS, Boehringer-Ingelheim, GSK, Janssen, Lilly, Novartis, Otsuka, Sanofi-Aventis, Servier et Vifor. Il a aussi reçu des subventions de recherche d’Amgen, Astra-Zeneca, Bayer, Boehringer-Ingelheim et Otsuka. Aucun autre intérêt concurrent n’a été déclaré. Déclaration d’intérêts: Cette étude a bénéficié du soutien de l’IRSS, qui reçoit une subvention annuelle du ministère de la Santé et des Soins de longue durée (MSSLD) de l’Ontario. Les opinions, résultats et conclusions présentés dans cet article n’engagent que ses auteurs et sont indépendants des sources de financement. Aucun appui de la part de l’ICES ou du MSSLD de l’Ontario n’est sous-entendu ni ne devrait être inféré.

Background: Patients undergoing long-term dialysis may be at higher risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and of associated disease and mortality. We aimed to describe the incidence, risk factors and outcomes for infection in these patients in Ontario, Canada., Methods: We used linked data sets to compare disease characteristics and mortality between patients receiving long-term dialysis in Ontario who were diagnosed SARS-CoV-2 positive and those who did not acquire SARS-CoV-2 infection, between Mar. 12 and Aug. 20, 2020. We collected data on SARS-CoV-2 infection prospectively. We evaluated risk factors for infection and death using multivariable logistic regression analyses., Results: During the study period, 187 (1.5%) of 12 501 patients undergoing dialysis were diagnosed with SARS-CoV-2 infection. Of those with SARS-CoV-2 infection, 117 (62.6%) were admitted to hospital and the case fatality rate was 28.3%. Significant predictors of infection included in-centre hemodialysis versus home dialysis (odds ratio [OR] 2.54, 95% confidence interval [CI] 1.59-4.05), living in a long-term care residence (OR 7.67, 95% CI 5.30-11.11), living in the Greater Toronto Area (OR 3.27, 95% CI 2.21-4.80), Black ethnicity (OR 3.05, 95% CI 1.95-4.77), Indian subcontinent ethnicity (OR 1.70, 95% CI 1.02-2.81), other non-White ethnicities (OR 2.03, 95% CI 1.38-2.97) and lower income quintiles (OR 1.82, 95% CI 1.15-2.89)., Interpretation: Patients undergoing long-term dialysis are at increased risk of SARS-CoV-2 infection and death from coronavirus disease 2019. Special attention should be paid to addressing risk factors for infection, and these patients should be prioritized for vaccination., Competing Interests: Competing interests: Leena Taji, Doneal Thomas, Jane Ip, Yiwen Tang, Angie Yeung and Rebecca Cooper are salaried employees of Ontario Renal Network, Ontario Health. Matthew Oliver, Phil McFarlane and Peter Blake are contracted Medical Leads at Ontario Renal Network, Ontario Health. Matthew Oliver is owner of Oliver Medical Management Inc., which licenses Dialysis Management Analysis and Reporting System software. He has received honoraria for speaking from Baxter Healthcare and participated on Advisory Boards for Janssen and Amgen. Peter Blake has received honoraria from Baxter Global for speaking engagements. Andrew House has received honoraria from Baxter for speaking engagements. Phil McFarlane has received consultant or lecture fees from Amgen, Astra-Zeneca, Bayer, BMS, Boehringer-Ingelheim, GSK, Janssen, Lilly, Novartis, Otsuka, Sanofi-Aventis, Servier and Vifor. He has also received research grants from Amgen, Astra-Zeneca, Bayer, Boehringer-Ingelheim and Otsuka. No other competing interests were declared., (© 2021 Joule Inc. or its licensors.)

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., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Haemoptysis is an uncommon presenting symptom in children and is usually caused by acute lower respiratory tract infection or foreign body aspiration. We report a rare case of right unilateral pulmonary vein atresia (PVA) as the underlying aetiology of recurrent haemoptysis in a child., Case Presentation: A 4 years old girl presented with history of recurrent haemoptysis. Bronchoscopic evaluation excluded a foreign body aspiration but revealed right bronchial mucosal hyperaemia and varices. Diagnosis of right unilateral PVA was suspected on transthoracic echocardiography which demonstrated hypoplastic right pulmonary artery and non-visualization of right pulmonary veins. Final diagnosis was confirmed on cardiac CT angiography. A conservative treatment approach was opted with consideration for pneumonectomy in future when she is older., Conclusion: Rarer causes should be considered when investigating for recurrent haemoptysis in children. Bronchoscopy and cardiac imaging are useful tools to establish the diagnosis of unilateral PVA in our case.

Background: Nasal lavage with mupirocin has the potential to reduce sinonasal morbidity in endoscopic endonasal approaches for skull base surgery., Objective: To evaluate the effects of nasal lavage with and without mupirocin after endoscopic endonasal skull base surgery., Methods: A pilot randomised, controlled trial was conducted on 20 adult patients who had undergone endoscopic endonasal approaches for skull base lesions. These patients were randomly assigned to cohorts using nasal lavages with mupirocin or without mupirocin. Patients were assessed in the out-patient clinic, one week and one month after surgery, using the 22-item Sino-Nasal Outcome Test questionnaire and nasal endoscopy., Results: Patients in the mupirocin nasal lavage group had lower nasal endoscopy scores post-operatively, and a statistically significant larger difference in nasal endoscopy scores at one month compared to one week. The mupirocin nasal lavage group also showed better Sino-Nasal Outcome Test scores at one month compared to the group without mupirocin., Conclusion: Nasal lavage with mupirocin seems to yield better outcomes regarding patients' symptoms and endoscopic findings.

We studied the ethmoidal arteries using preexisting computer tomography of the paranasal sinuses (CT PNS) and statistically scrutinized data obtained between genders. A descriptive study from 77 CT PNS dated January 2016-December 2016 were collected and reviewed by two radiologists. A total of 54 (108 sides) CT PNS were studied of patients aged 18-77 years. 37 are male, 17 are female; with Bumiputera Sarawak predominance of 25 patients, 12 Malays, 16 Chinese and one Indian. Rate of identification are as follows: anterior ethmoidal artery (AEA)-100%, middle ethmoidal artery (MEA)-30%, posterior ethmoidal artery (PEA)-86%. The average distance from AEA-MEA is 8.1 ± 1.52 mm, MEA-PEA is 5.5 ± 1.29 mm and AEA-PEA is 12.9 ± 1.27 mm. The mean distance from PEA-the anterior wall of sphenoid is 7.7 ± 3.96 mm, and PEA-optic canal is 8.5 ± 3.1 mm with no statistical difference when compared between gender. AEA frequently presented with a long mesentery 57.4%, while 87.1% of PEA was hidden in a bony canal. The vertical distance of the AEA-skull base ranges from 0 to 12.5 mm whilst PEA-skull base is 0-4.7 mm. There is no statistical difference in distances of AEA, MEA nor PEA to skull base when analyzed between genders; t(82) = 1.663, p  > 0.05, t(32) = 0.403, p  > 0.05 and t(75) = 1.333, p  > 0.05 respectively. We newly discovered, that 50% of MEA is hidden in a bony canal, and its distance to skull base ranged 0-5.3 mm. MEA and PEA less commonly have a short or long mesentery. Knowledge on the ethmoidal arteries especially in our unstudied population of diverse ethnicity, gains to assist surgeons worldwide, when embarking in endoscopic transnasal surgeries., Competing Interests: Conflicts of interestAuthors J has completed this research as part of her fulfillment in obtaining her Masters degree in Otolaryngology. All other authors declare no conflicts of interest pertaining to this study., (© Association of Otolaryngologists of India 2018.)

H1-antihistamines are recognized to be effective for conditions such as allergic rhinitis and chronic spontaneous urticaria. However, management of such conditions in the real-world primary care setting may be challenging due to diverse patient-specific considerations, the wide range of antihistamines available, choice of other treatment modalities, and the complexity of interpreting specialist treatment algorithms. Despite regular updates to international guidelines, regional/national surveys of healthcare professionals show a clear gap between guidelines and real-world practice, particularly at the primary care level. This article thus presents the consensus opinion of experts from relevant specialties in Malaysia - allergology, pediatrics, otorhinolaryngology, and dermtology - on harmonizing the use and choice of antihistamines in primary care. Patient profiling is recommended as a tool to guide primary care practitioners in prescribing the appropriate antihistamine for each patient. Patient profiling is a three-step approach that involves 1) identifying the individual's needs; 2) reviewing patient-specific considerations; and 3) monitoring treatment response and referral to specialists in more severe or difficult-to-treat cases. Concurrently, guidelct 3ines should be reviewed and updated periodically to include recommendations that are easily actionable for primary care practitioners., Competing Interests: The authors report no conflicts of interest in this work., (© 2019 Baharudin et al.)

Cervico facial cystic hygroma and tongue lymphagioma is rare representative of spectrum of lymphatic malformations. Conservative management with sclerosants alone has proven to be successful. However, sudden enlargement of these cervico facial lymphangiomas leads to catastrophic airway obstruction leading to debility in feeding and speech. Therefore, surgery is indicated in such case to prevent such a catastrophic problem. We report here the case of a 3-yearold boy with cervico facial hygroma involving the tongue. We successfully treated him with a combination of surgery and OK432 injection.

Laryngeal leiomyosarcoma is a rare smooth muscle malignancy of the head and neck region. Diagnosis is based on immunohistochemistry. Here we present a case of laryngeal leiomyosarcoma that was diagnosed and treated in our center, focusing on the clinical features, histological diagnosis and management of this rare disease., (© Association of Otolaryngologists of India 2018.)

Adenoid cystic carcinomas are tumors that are more commonly seen in the salivary glands than in the nasopharynx. Nasopharyngeal adenoid cystic carcinomas are rare and cases that are reported in the literatures are few. Treatment is mainly by surgical resection. Here, we report 2 cases of nasopharyngeal adenoid cystic carcinoma., (© Association of Otolaryngologists of India 2018.)

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.

Intracranial fungal infection of the cavernous sinus is a condition that usually affects immunocompromised individuals and is rarely seen in immunocompetent individuals. It is a potentially life threatening condition which requires prompt treatment. Here we present a case of an immunocompetent patient with a fungal infection of the cavernous sinus.

Introduction: Congenital hearing loss is one of the commonest congenital anomalies. Neonatal hearing screening aims to detect congenital hearing loss early and provide prompt intervention for better speech and language development. The two recommended methods for neonatal hearing screening are otoacoustic emission (OAE) and automated auditory brainstem response (AABR)., Objective: To study the effectiveness of distortion product otoacoustic emission (DPOAE) and automated auditory brainstem response (AABR) as first screening tool among non-risk newborns in a hospital with high delivery rate., Method: A total of 722 non-risk newborns (1444 ears) were screened with both DPOAE and AABR prior to discharge within one month. Babies who failed AABR were rescreened with AABR ± diagnostic auditory brainstem response tests within one month of age., Results: The pass rate for AABR (67.9%) was higher than DPOAE (50.1%). Both DPOAE and AABR pass rates improved significantly with increasing age (p-value<0.001). The highest pass rate for both DPOAE and AABR were between the age of 36-48 h, 73.1% and 84.2% respectively. The mean testing time for AABR (13.54 min ± 7.47) was significantly longer than DPOAE (3.52 min ± 1.87), with a p-value of <0.001., Conclusions: OAE test is faster and easier than AABR, but with higher false positive rate. The most ideal hearing screening protocol should be tailored according to different centre., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose of Review: Sphenoid sinus lateral recess encephalocoeles (SSLRE) are rare occurrences and pose unique challenges due to limited surgical access for endoscopic endonasal repair and also the lack of consensus on optimal perioperative managements specifically in the spontaneous cases, which are also believed to be a variant of idiopathic intracranial hypertension (IIH). Endoscopic endonasal approaches have largely replaced the transcranial route and the techniques are continuously being refined to reduce the neurovascular morbidity and improve outcome., Recent Findings: Transpetrygoid is the most utilized approach with modifications suggested to limit bone removal, exposure and preservation of the neurovascular structures as dictated by the extent of the lateral recess. As more experience is gained, extended transphenoidal techniques were also successfully used for access. Lateral transorbital is a new approach to the lateral recess investigated in cadavers. IIH treatment is still controversial in the setting of SSLRE, but it appears rationale to evaluate, monitor and treat if necessary., Summary: SSLRE management should be tailored to the specific anatomical variances and cause. Modifications of techniques have been described giving different options to access the lateral recess. Successful repair for spontaneous SSLRE may require treatment of IIH if present, but the long-term outcome is still unclear.

Auditory brainstem implantation (ABI) is the only solution to restore hearing when cochlear nerves are disrupted together with the pathologies where bilateral cochleae do not provide a suitable location for cochlear implantation. We reported first two successful auditory brainstem implantation cases in patients with neurofibromatosis Type II (NF2) with bilateral acoustic neuroma causing bilateral profound sensorineural hearing loss in Malaysia. A good candidate selection, dedicated surgeons and rehabilitation team as well as strong family support are the crucial factors in achieving the best possible surgical, audiological and speech outcomes.

Objectives: To investigate the surgical and audiological outcome of Bonebridge (BB) at tertiary centres in Malaysia., Study Design: Prospective, intra-subject repeated measurements of which each subject is his/her own control, from year 2012 to 2016 at two tertiary referral centres., Methods: Twenty patients with hearing loss who fulfilled criteria for BB and showed good response to bone conduction hearing aid trial were included. Implantations of BB were carried out under general anaesthesia with preoperative computed tomography (CT) planning. Complications were monitored up to six months postoperatively. Subjects' audiometric thresholds for air conduction, bone conduction and sound field at frequencies of 250Hz to 8kHz were assessed preoperatively and at six months postoperatively. Subjects' satisfaction was evaluated at 6 months post operatively with Hearing Device Satisfaction Scale (HDSS) questionnaire., Results: There was no major complication reported. Mean aided sound field thresholds showed significant improvement for more than 30dB from 500 to 4000kHz (p<0.05). There was no significant change in mean unaided air conduction and bone conduction thresholds pre and post operatively from 500 to 4000kHz, with a difference of less than 5dB (p>0.05). All the patients were very satisfied (>80%) with the implant, attributing to the promising functional outcome and acceptable cosmetic appearance., Conclusions: BB implantation surgery is safe and is effective in restoring hearing deficits among patients aged five and above with conductive or mixed hearing loss and single-sided hearing loss.

Objectives: To investigate the surgical and audiological outcomes of the Bonebridge transcutaneous bone conduction hearing implant among children with congenital aural atresia., Methods: Six children were recruited and underwent Bonebridge transcutaneous bone conduction implant surgery. The patients' audiometric thresholds for air conduction, bone conduction and sound-field tests were assessed pre-operatively and at six months post-operatively. Patients' satisfaction was assessed at six months post-operatively with the Hearing Device Satisfaction Scale., Results: No major complications were reported. Mean aided sound-field thresholds improved post-operatively by more than 30 dB for 0.5-4 kHz (p 0.05). All patients were satisfied (scores were over 90 per cent) with the implant in terms of functional outcome and cosmetic appearance., Conclusion: Bonebridge transcutaneous bone conduction implant surgery is safe and effective among children with congenital aural atresia with conductive hearing loss.

Introduction: Endoscopic sinus surgery (ESS) is the mainstay for treatment of chronic rhinosinusitis versus maximal medical therapy. We propose a more economical option, by using steroid-impregnated Gelfoam instead of Nasopore post ESS, as it is less expensive and has showed effectiveness in preventing post-operative bleeding., Materials and Methods: A randomised, double-blinded, placebo-controlled trial was carried out in eight patients with chronic rhinosinusitis or nasal polyposis who were planned for bilateral endoscopic sinus surgery. A Peri-operative Sinus Endoscopy (POSE) Score and Lund-Kennedy Endoscopic Score (LKES) were recorded. The use of hydrocortisone-impregnated Gelfoam dressing versus normal saline-impregnated Gelfoam dressing were compared. Scores were repeated post-operatively at one week, three weeks and three months interval., Results: For LKES, at the end of three months, 50% of the patients had the same score difference, 37.5% had better results on the study side while 12.5% had better results on the control side. Meanwhile, for POSE Score, at the end of three months, 75% of the patients had better score difference on the study side while 12.5% had better results on the control side., Conclusion: Gelfoam can be used as nasal packing material to deliver topical steroid after endoscopic sinus surgery. Steroid-impregnated nasal dressing after endoscopic sinus surgery may not provide better long-term outcome.

OBJECTIVE The endoscopic endonasal approach (EEA) offers direct access to midline skull base lesions, and the anterior transpetrosal approach (ATPA) stands out as a method for granting entry into the upper and middle clival areas. This study evaluated the feasibility of performing EEA for tumors located in the petroclival region in comparison with ATPA. METHODS On 8 embalmed cadaver heads, EEA to the petroclival region was performed utilizing a 4-mm endoscope with either 0° or 30° lenses, and an ATPA was performed under microscopic visualization. A comparison was executed based on measurements of 5 heads (10 sides). Case illustrations were utilized to demonstrate the advantages and disadvantages of EEA and ATPA when dealing with petroclival conditions. RESULTS Extradurally, EEA allows direct access to the medial petrous apex, which is limited by the petrous and paraclival internal carotid artery (ICA) segments laterally. The ATPA offers direct access to the petrous apex, which is blocked by the petrous ICA and abducens nerve inferiorly. Intradurally, the EEA allows a direct view of the areas medial to the cisternal segment of cranial nerve VI with limited lateral exposure. ATPA offers excellent access to the cistern between cranial nerves III and VIII. The quantitative analysis demonstrated that the EEA corridor could be expanded laterally with an angled drill up to 1.8 times wider than the bone window between both paraclival ICA segments. CONCLUSIONS The midline, horizontal line of the petrous ICA segment, paraclival ICA segment, and the abducens nerve are the main landmarks used to decide which approach to the petroclival region to select. The EEA is superior to the ATPA for accessing lesions medial or caudal to the abducens nerve, such as chordomas, chondrosarcomas, and midclival meningiomas. The ATPA is superior to lesions located posterior and/or lateral to the paraclival ICA segment and lesions with extension to the middle fossa and/or infratemporal fossa. The EEA and ATPA are complementary and can be used independently or in combination with each other in order to approach complex petroclival lesions.

Background: Angioleiomyoma of the nasal cavity is an extremely rare benign neoplasm. It usually occurs in the lower extremities. Up to date, only few cases of angioleiomyoma have been reported. First case of angioleiomyoma of nasal cavity was reported in 1966. We report a rare case of angioleiomyoma arising from the right maxillary sinus., Case Report: A 43-year-old lady presented with recurrent epistaxis and right nasal obstruction for two months duration. Clinical examination revealed a huge right nasal mass obstructing the right nasal cavity. The tumour was excised completely via endoscopic endonasal surgical approach. Histopathological examination confirmed the tumour is sinonasal angioleiomyoma. Postoperatively, she recovered well without any recurrence after a year of followup., Conclusion: This tumour has an excellent prognosis and recurrence is extremely rare if excised completely.

Purpose of Review: To review cause, clinical evaluation, medical and surgical management of isolated sphenoid sinus diseases., Recent Findings: Early diagnosis of isolated sphenoid sinus diseases requires a high index of clinical suspicion and appropriate radiological imaging. Sphenoid sinus can be approached endoscopically via a few different surgical techniques., Summary: Isolated sphenoid sinus diseases are uncommon, with nonspecific clinical presentation. Early diagnosis requires a high index of clinical suspicion, proper endoscopic nasal examination, and appropriate radiological imaging. Surgical intervention is the primary treatment modality for most of the isolated sphenoid sinus diseases. Endoscopic endonasal approach to sphenoid sinus is the technique of choice. The location of sphenoid sinus disease, the extent of the surgery, and anatomic configuration of the sphenoid sinus are the main factors that help to decide the most suitable surgical approach to the sphenoid sinus.

High acoustic noise level is one of the unavoidable side effects of 3 T magnetic resonance imaging (MRI). A case of hearing loss after 3 T MRI has been reported in this institution and hence this study. The objective of this study was to determine whether temporary threshold shift (TTS) in high frequency hearing occurs in patients undergoing 3 T MRI scans of the head and neck. A total of 35 patients undergoing head and neck 3 T MRI for various clinical indications were tested with pure tone audiometry in different frequencies including high frequencies, before and after the MRI scan. Any threshold change from the recorded baseline of 10 dB was considered significant. All patients were fitted with foamed 3 M earplugs before the procedure following the safety guidelines for 3 T MRI. The mean time for MRI procedure was 1,672 s (range 1,040-2,810). The noise dose received by each patient amounted to an average of 3,906.29% (1,415-9,170%). The noise dose was derived from a normograph used by Occupational Noise Surveys. This was calculated using the nomograph of L eq, L EX, noise dose and time. There was no statistically significant difference between the hearing threshold before and after the MRI procedures for all the frequencies (paired t test, P > 0.05). For patients using 3 M foamed earplugs, noise level generated by 3 T MRI during routine clinical sequence did not cause any TTS in high frequency hearing.

Background and Methods: Reconstruction with a vascularised flap provides the most reliable outcome, with post-operative cerebrospinal fluid leak rates of less than 5 per cent. This article aims to review and summarise the critical technical aspects of the vascularised flaps most commonly used for skull base reconstruction., Results: Vascularised flaps are classified as intranasal or extranasal. The intranasal group includes the Hadad-Bassagaisteguy nasoseptal flap, the Caicedo reverse nasoseptal flap, the nasoseptal rescue flap, the posteriorly or anteriorly based lateral wall flaps, and the middle turbinate flap. Extranasal flaps include the transfrontal pericranial and transpterygoid temporoparietal flaps., Conclusion: The Hadad-Bassagaisteguy nasoseptal flap is overwhelmingly favoured for reconstructing extensive defects of anterior, middle and posterior cranial base. Its pertinent technical features are described. However, it is essential to master the skills required for the various extranasal or regional vascularised flaps because each can offer a reconstructive alternative for specific patients, especially when open approaches are needed and/or intranasal vascularised flaps are not feasible.

Lipoblastoma is extremely rare and mainly occurs in children younger than 3 years old. It is predominantly found in the extremities and trunk. Head and neck region occurrences are rare; only 4 such cases involving patients who presented with stridor have been previously reported. We report the fifth case of lipoblastoma of the neck with stridor in a 9-year-old girl, which had gradually worsened over the previous year. Imaging showed a retrotracheal mass extending superiorly to the thyroid level and inferiorly to below the carina of the trachea. Total resection of the tumor was performed, and the histopathologic findings were consistent with lipoblastoma. Postoperatively, the patient was well with no complications.

Objective: The objectives of this study were to determine the presence of epithelial migration in patients with postirradiated nasopharyngeal carcinoma (NPC) and to compare the rate of epithelial migration in the tympanic membrane (TM) and the bony external auditory canal (EAC) of postirradiated NPC ears with normal ears by means of the ink dot method., Study Design: Prospective, nonrandomized case-control study involving patients with NPC and control subjects with healthy ears seen in an otorhinolaryngology outpatient clinic., Setting: Otorhinolaryngology Outpatient Clinic, University Malaya Medical Centre, Kuala Lumpur., Patients: Patients with NPC who have completed radiotherapy and patients with normal ear presenting with other complaints., Intervention: Patients who fulfilled the inclusion and exclusion criteria were chosen for this study. All the selected patients' ears were visualized under a microscope and were cleaned, and ink dots were applied at the umbo and annulus. They were followed up on a 2- to 3-weekly basis until the ink dots reached the specified landmarks. The distance and pattern of migration were recorded and calculated. The mean radiation dose received by both the right and left TM and EAC was mapped and calculated., Main Outcome Measures: Rate and pattern of epithelial migration in the NPC group compared with that in the control group., Results: The mean radiation dose to both the TM and EAC did not show a significant difference (p > 0.05). The entire TM study group showed epithelial migration from the umbo toward the annulus and EAC, except in 1 ear. The mean rate of epithelial migration on the TM of the study group was 51.35 μm/d compared with that on the control group, which was 64.68 μm/d, and this difference was statistically significant (p < 0.05). Of the ears in the control group, 42.5% showed a migration pattern toward the posterior-superior direction, whereas 45% of the ears in the study group showed a migration pattern toward the posterior-inferior direction. In the EAC of the study group, the mean epithelial migration was noted to be accelerated compared to that of the control group (144.75 and 94.33 μm/d, respectively; p < 0.05). The mean rate of migration between the TM and the EAC was also different. Both the study and control groups showed a significant difference in migration, with a faster rate of migration in the EAC (p < 0.05)., Conclusion: We noted a significant delay in the rate of epithelial migration in the TM of patients with postirradiated NPC and an accelerated rate of migration in the EAC of patients with postirradiated NPC. In addition, epithelial migration in the EAC was also noted to be faster than that in the TM of the control population.

Case Report: Five cases of Kimura's disease had been treated in our centre from year 2003 to 2010. All cases were presented with head and neck mass with cervical lymphadenopathy. Surgical excision was performed for all cases. Definite diagnosis was made by histopathological examination of the resected specimens. One out of five cases developed tumour recurrence four years after resection., Conclusion: Surgical excision is our choice of treatment because the outcome is immediate and definite tissue diagnosis is feasible after resection. Oral corticosteroid could be considered as an option in advanced disease. However, tumour recurrence is common after cessation of steroid therapy.

Nontuberculous Mycobacterium (NTM) middle ear infection is a rare cause of chronic bilateral intermittent otorrhea. We report a rare case of bilateral NTM middle ear infection in which a 55-year-old woman presented with intermittent otorrhea of 40 years' duration. The patient was treated medically with success. We conclude that NTM is a rare but probably under-recognized cause of chronic otitis media. A high index of suspicion is needed for the diagnosis to avoid prolonged morbidity. Treatment includes surgical clearance of infected tissue with appropriate antimycobacterial drugs, which are selected based on culture and sensitivity.

Aim: This was a randomized single blinded study to determine optimal size for Ambu®LMA (ALMA) among Malaysian adult population., Methods: One hundred and twenty six non-paralyzed anaesthetized adult patients were block randomized into size 3, 4 and 5 Ambu®LMA. Optimal size is defined primarily by oropharyngeal pressure (OLP). Pharyngeal injury and ease of insertion are also taken into consideration., Results: Mean OLP was significantly higher for Size 4 and 5 compared to size 3 (p<0.001) but similar between size 4 and 5. Number of insertion attempts and insertion time were similar between sizes. Size 5 required more manipulations during insertion (p<0.005) and had higher pharyngeal injury (p=0.001) compared to size 3 and 4., Discussion: We recommend size 4 ALMA as the optimal size for Malaysian adults in view of the higher OLP compared to size 3, yet less pharyngeal injury than size 5 in spontaneously breathing patients.

Objective: To review the postoperative surgical outcomes of cystic vestibular schwannomas (CVSs), especially facial nerve outcomes, and compare these results with those from matched solid vestibular schwannomas (SVS) resected during the same period at a tertiary referral center., Study Design: Retrospective case series., Methods: One hundred thirty-one surgically managed patients with cystic vestibular schwannomas (CVSs) were age, sex, and tumor size matched to 131 surgically managed patients with solid vestibular schwannomas (SVSs). Demographics, tumor morphology, surgical approach, extent of resection, facial and nonfacial complications, and recurrence rates were compared between the 2 groups. Subtotal removal was defined as removal of at least 95% of the tumor., Results: The mean maximal tumor diameter was 2.8 cm for both groups. For CVS, gross total tumor resection (GTR) was achieved in 92 patients (70.2%), and subtotal tumor resection (STR) was achieved in 39 patients (29.8%). Postoperative facial nerve outcomes at 1-year follow-up were good (HB Grade I-III) in 116 (88.5%) of 131 CVS patients. Twenty-three patients developed nonfacial nerve-related complications (17.6%). For SVS, GTR was achieved in 102 patients (77.9%), and STR was achieved in 29 patients (22.1%). Postoperative facial nerve outcomes at 1-year follow-up were good (HB Grade I-III) in 118 (90.1%) of 131 SVS patients. Nonfacial nerve related complications occurred in 14 patients (10.7%). None of the differences in outcome between the 2 groups were statistically significant., Conclusion: The difference in surgical outcomes is minimal between patients with CVS and those with SVS, not reaching statistical significance. We think, with judicious surgical management, similar outcomes can be achieved in cystic tumors and solid tumors.

Isolated intrasellar pituitary mucocele following transsphenoidal sinus surgery is extremely rare. The clinical features resemble a pituitary tumor, therefore careful radiological interpretation is crucial to reach the correct diagnosis. We report a case of intrasellar mucocele who had transsphenoidal sinus surgery performed 15 years prior.

Objective: To systematically summarise the peer-reviewed literature relating to the aetiology, clinical presentation, investigation and treatment of geniculate neuralgia., Data Sources: Articles published in English between 1932 and 2012, identified using Medline, Embase and Cochrane databases., Methods: The search terms 'geniculate neuralgia', 'nervus intermedius neuralgia', 'facial pain', 'otalgia' and 'neuralgia' were used to identify relevant papers., Results: Fewer than 150 reported cases were published in English between 1932 and 2012. The aetiology of the condition remains unknown, and clinical presentation varies. Non-neuralgic causes of otalgia should always be excluded by a thorough clinical examination, audiological assessment and radiological investigations before making a diagnosis of geniculate neuralgia. Conservative medical treatment is always the first-line therapy. Surgical treatment should be offered if medical treatment fails. The two commonest surgical options are transection of the nervus intermedius, and microvascular decompression of the nerve at the nerve root entry zone of the brainstem. However, extracranial intratemporal division of the cutaneous branches of the facial nerve may offer a safer and similarly effective treatment., Conclusion: The response to medical treatment for this condition varies between individuals. The long-term outcomes of surgery remain unknown because of limited data.

Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

Objectives/hypothesis: A pedicled nasoseptal flap is our preferred reconstructive technique after endoscopic endonasal skull base surgery. Its harvesting implies that the donor site (septal cartilage) is left bare. Secondary healing leads to crusting at the donor site that negatively affects the patient's quality of life and requires multiple outpatient debridements. A nasoseptal reverse rotation flap was designed to eliminate this problem; however, its outcomes have not been reported., Study Design: Retrospective review., Methods: We retrospectively reviewed the clinical charts of patients who underwent endoscopic endonasal skull base surgery at the Wexner Medical Center at The Ohio State University from November 2010 to September 2012, and in whom a reverse flap was used. We analyzed patients' demographics, pathology, and outcomes regarding the reverse flap., Results: Forty-nine patients with various pathologies were included (11 meningiomas, seven craniopharyngiomas, five pituitary macroadenomas, five chondrosarcomas, five meningoencephaloceles, three chordomas, 11 malignant tumors, two other lesions). There were two patients lost to follow-up. Mean follow-up time was 11 weeks (range = 1-39 weeks). A follow-up examination 1 to 2 weeks after surgery revealed a complete re-epithelialization in 46 of 47 patients (97.87%). Adverse events included granuloma (n = 1), anterior dehiscence (n = 1), and excoriated mucosa (n = 1). Factors such as underlying disease, prior chemoradiotherapy, and postoperative chemoradiotherapy did not seem to affect the healing of the reverse flap., Conclusions: The reverse flap provides complete remucosalization of the denuded donor septum, decreasing septal crusting within the first 1 to 2 postoperative weeks, and adds minimal morbidity., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Primary lacrimal sac lymphoma is rare. The common clinical features are epiphora and medial canthal swelling which mimic nasolacrimal duct obstruction. Histological examination is therefore important to avoid delay in diagnosis and treatment. We report a case of primary lacrimal sac lymphoma in a 72-year-old female who developed a metachronous tumour at the hard palate one year after excision of the lacrimal sac tumour.

Objectives: To identify the common bacteria of otorhinolaryngological (ORL) infection in three general hospitals in the state of Sarawak, East Malaysia and to determine the antibiotic sensitivity of the common bacteria to update local antibiotic policy., Methods: All specimens with positive monoclonal culture, received from inpatient and outpatient Otorhinolaryngology Department in the year 2009 and 2010 were included in the study. Patients' demographics, nature of specimens, bacterial isolates and antibiotic sensitivity were analysed by using the Statistical Package for the Social Sciences (SPSS)., Results: A total 244 positive monoclonal cultures were identified. Staphylococcus species and Gram negative bacilli were the commonest bacteria of ORL infections. Common ORL bacteria remain sensitive to our front line antibiotics. There are a number of multi-drug resistant isolates of MRSA, ESBL Klebsiella pneumoniae and Acinetobacter baumanii in the hospital-acquired infections., Conclusion: Although resistance to antimicrobial agents is growing worldwide, first line antibiotics still show significant therapeutic advantage in our local setting. The low resistance of bacterial isolates in our community reflects judicious use of antibiotics in our routine clinical practices.

Congenital cholesteatoma (CC) rarely presents with Luc's abscess. As a result of widespread usage of antimicrobial agents, Luc's abscess is hardly encountered in current clinical practice. Herein, we report a case of Luc's abscess as the first presenting symptom in a 5-year-old boy with underlying CC. Patient's clinical findings, radiological investigations and treatment were also discussed., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2012.)

The Vibrant Soundbridge is a new middle ear implantable hearing device. It was first introduced for adult patients with moderate to severe sensorineural hearing loss. With the innovation of the surgical techniques, its usage had been broadened for children and those patients with conductive and mixed hearing loss. We report first two cases of monoaural Vibrant Soundbridge implantation in Malaysia. They were children with bilateral conductive hearing loss who had failed to benefit from previous hearing aids. Floating mass transducers were attached in oval window and long process of incus respectively. Remarkable hearing yield was observed without surgical complication.