Challenges in Managing Intractable Epistaxis in a Post-nasal Surgery and Radiated Cancer Patient: A Case Report and Literature Review.

Recurrent epistaxis represents an alarming sign that may suggest a sinister aetiology, especially in patients with previous head and neck malignancy. The recognition of certain potentially life-threatening conditions, namely pseudoaneurysm or tumour recurrence, remains prudence to avoid disastrous repercussion. Nasal endoscopy has become an essential tool in otolaryngology. It can aid identify the underlying cause of epistasis and facilitate therapeutic management. On the other hand, radio imaging is highly sensitive in detecting vascular lesions, besides providing a pre-operative mapping if surgical intervention is planned. This paper reported a patient with sphenoidal sinus squamous cell carcinoma in remission presented with torrential epistaxis not relieved with nasal packing. Despite a repeated angiogram and magnetic resonance image, the identification of the source of bleeding remained futile, culminating in an examination under general anaesthesia. The diagnosis of carotid blowout syndrome was made intraoperatively, and the bleeding was temporarily secured with a muscular patch, preceded by the insertion of a vascular stent. The authors wish to highlight the importance of examination under general anaesthesia if radio imaging does not correlate to the clinical findings. Management options for carotid blowout should be tailored to the patients' medical conditions. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03625-4.

Temporal bone squamous cell carcinoma: A change in treatment.

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.

Effects of nasal lavage with and without mupirocin after endoscopic endonasal skull base surgery: a randomised, controlled study.

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.

Dilemma in management of cervico-facial cystic hygroma.

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.

A review of surgical and audiological outcomes of bonebridge at tertiary centres in Malaysia.

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.

A new experience of auditory brainstem implantation in Malaysia.

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.

Pilot study comparing steroid-impregnated and non-steroid-impregnated absorbable nasal dressing following endoscopic sinus surgery.

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.

Bonebridge transcutaneous bone conduction implant in children with congenital aural atresia: surgical and audiological outcomes.

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.

Sinonasal angioleiomyoma.

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.

Technical nuances of commonly used vascularised flaps for skull base reconstruction.

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.

Optimal Size AMBU® Laryngeal Mask Airway Among Asian Adult Population.

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.

Geniculate neuralgia: a systematic review.

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.

Kimura's Disease: Diagnostic Challenge and Treatment Modalities.

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.

Primary lacrimal sac lymphoma with recurrence: a case report.

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.

Antibiotic sensitivity and spectrum of bacterial isolates in otorhinolaryngological infection: a retrospective study.

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.

Small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses: a rare case.

OBJECTIVE: We report a rare case of small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses with intracranial extension, and discuss the management of this rare tumour. RESULTS: Small cell neuroendocrine carcinoma involving the nasal cavity and paranasal sinuses with intracranial extension may be treated successfully with surgery alone, without development of local recurrence. CONCLUSION: Small cell neuroendocrine carcinoma is a locally aggressive tumour with a high rate of recurrence. Early and aggressive surgical excision with or without radiotherapy or chemotherapy can improve a patient's outcome and prognosis. Regular follow up is needed to detect any local or distant recurrence.

Nasolacrimal relapse of nasopharyngeal carcinoma.

OBJECTIVES: To describe three rare cases of nasolacrimal relapse of nasopharyngeal carcinoma, and to discuss the route of tumour spread from nasopharynx to lacrimal system as well as the relevant computed tomography findings. CASE REPORT: We report three cases of nasolacrimal relapse in patients with previously treated nasopharyngeal carcinoma. The common initial presentations in these cases were epiphora and medial canthal swelling. The tumour spread from the nasopharynx to the lacrimal sac along the lateral nasal wall and nasolacrimal canal. Computed tomography demonstrated nasolacrimal canal invasion and osteomeatal complex obliteration by the tumour. Distant metastasis was detected in two cases. CONCLUSION: More targeted radiotherapy should be delivered to prevent under-treatment of nasopharyngeal carcinoma. Nasolacrimal relapse of nasopharyngeal carcinoma is an advanced disease with a poor prognosis.

Multiple symmetrical lipomatosis: case report and literature review.

OBJECTIVE: To discuss the pathophysiology and various treatment methods of multiple symmetrical lipomatosis. CASE REPORT: We report a case of multiple symmetrical lipomatosis in a middle-aged man. He presented to us with an extensive, disfiguring neck mass. Clinical examination and computed tomography suggested a lipomatous mass without compression of vital neck structures. The proximity of the lipomatous mass to the carotid sheaths attracted our interest. We performed surgical excision in this case, because of the deep infiltrative behaviour of the lipoma. The benefits and drawbacks of liposuction and surgical excision of extensive neck lipomatosis are discussed. CONCLUSION: Surgical excision and liposuction are complementary treatments in the management of multiple symmetrical lipomatosis. Patients should be aware of the limitations of both surgical options, and the risk of lipoma recurrence, before surgery. The decision on the mode of surgery relies upon the disease extent, the patient's expectations and the surgeon's experience.

Grisel's syndrome: a rare complication of tonsillectomy.

OBJECTIVES: To discuss the pathophysiology of atlanto-axial subluxation as a rare complication of tonsillectomy, and to discuss the important radiological findings for diagnosis and treatment planning. CASE REPORT: We report a case of post-tonsillectomy atlanto-axial subluxation, also known as Grisel's syndrome, in a child. On the third day after surgery, the boy presented with torticollis with no neurological deficit. Rotatory atlanto-axial subluxation was clearly shown in computed tomography scans of the neck. Cervical traction for one week successfully reduced the subluxation, with no long-term sequelae. CONCLUSION: Pre-existing cervical ligamentous laxity and post-operative infection are believed to be the main causes of Grisel's syndrome. Although it is rare, patients are advised to seek treatment early if any neck pain or fever persists. Early diagnosis is important for better treatment outcome. Initial conservative measures are advised before more invasive cervical traction is adopted.

Vibrant soundbridge: a new implantable alternative to conventional hearing AIDS in children.

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.