Long-term results of endoscopic resection of nasopharyngeal tumours.

Traditional open approaches to the nasopharynx either provide limited access and risk significant morbidity. Here we describe our experience with endoscopic resection of nasopharyngeal tumours. Retrospective chart review was performed for all patients who underwent endoscopic nasopharyngeal resection from September 1993 to January 2007 at a tertiary rhinology centre. Six patients underwent endoscopic nasopharyngectomy for tumours arising from or involving the nasopharynx. The mean age was 49.8 years (range 23 - 70). The sex distribution was five males and one female. Four tumours were malignant and two were benign. The mean disease-free and overall survival for malignant tumors was 90.75 months (range 66 - 120 months). None of the benign tumors recurred. The endoscopic nasopharyngectomy technique may be successfully used for resection of tumors arising from or involving the nasopharynx with good efficacy and a decrease in morbidity when compared to open approaches.

Isolated sphenoid lesions: diagnosis and management.

Isolated sphenoid lesions are rare. It is likely that isolated sphenoid sinus disease is underreported for a number of reasons. First, the presenting symptoms are often nonspecific; second, the inaccessibility of the sinus precludes optimal physical examination; and third, before the advent of CT and MRI scanning, radiologic examination of the sinus was inadequate. Endoscopic evaluation and current imaging techniques with CT or MRI have contributed to an increase in diagnosis of these lesions. Twenty-one patients with isolated sphenoid lesions that I treated in a 4-year period are presented. The pathology was unilateral sphenoid sinusitis (8), sphenoid mucoceles (4), inflammatory sphenochoanal polyp (3), inverting papilloma (2), invasive pituitary adenoma (1), carcinoma (1), aspergilloma (1), and fibrous dysplasia (1). Endoscopic biopsy was carried out in 7 patients (33.3%). A precise diagnosis after endoscopy, biopsy, and imaging studies was established in all patients. Definitive treatment included an endoscopic sphenoidotomy in 15 (71.4%). Five patients (23.8%) were treated with other therapeutic modalities. One patient did not require any definitive treatment. The combined use of imaging techniques and diagnostic nasal endoscopy allows for an accurate diagnosis and enables minimally invasive techniques to be tailored to the patient's disease.

Immunologic defects in patients with chronic recurrent sinusitis: diagnosis and management.

Twenty patients with chronic refractory sinusitis or rhinitis were identified to have immune defects on the basis of total immunoglobulin level, immunoglobulin G subclass, and vaccine response. Eight patients were immunoglobulin A deficient, five had low immunoglobulin levels with vaccine hyporesponse, and four had low immunoglobulin levels with normal vaccine responses. Three subjects showed isolated immunoglobulin G1 deficiency. Demographic variables such as age, sex, infection pattern, and any other related disorders were studied retrospectively, which may have contributed to the diagnosis. An immunologic screen was essential for the diagnosis of immunodeficiency in these patients. Treatment options included prophylactic antibiotics, management of associated allergies, functional endoscopic sinus surgery, and replacement therapy with immunoglobulin in selected patients.

Diagnostic and therapeutic approach to migrating foreign bodies.

Ingested foreign bodies are the commonest otolaryngological emergency in Singapore and other parts of Southeast Asia. One of the uncommon complications of ingested foreign bodies is migration, which has the potential to cause morbidity and mortality. A retrospective study of 24 patients presenting from 1990 to 1996 at Singapore General Hospital was done to evaluate the presentation, investigation, and diagnosis of migrated foreign bodies. Of interest, most patients had ingested foreign bodies within 24 hours. All the migrated foreign bodies were linear, sharp fish bones. Migration is said to have occurred in the presence of positive neck radiography and negative rigid esophagoscopy. Computed tomography is the investigation of choice to confirm migration. All patients had neck exploration, and factors for successful outcome are discussed. This is the largest series in the literature to date.

Parapharyngeal abscesses.

Fifty-five patients with deep neck infections treated consecutively over a period of six and a half years between January 1983 and July 1989 were reviewed. Nine of these patients had abscesses localized to the pharapharyngeal space and form the basis of this study. The aetiology of the parapharyngeal abscess was odontogenic in two patients and remained unknown in the other seven. Five patients had associated systemic disease; four were diabetics and one patient had non-Hodgkin's Lymphoma. High dosage intravenous antibiotics directed towards the causative micro-organisms, airway control and early surgical intervention was the mainstay of treatment. All patients underwent open surgical drainage of the parapharyngeal abscess within 24 h of admission. Bacteriology results showed Klebsiella sp. to be the dominant micro-organism cultured in four patients. Morbidity was low; seven patients had no post-operative complications and were discharged from the hospital between 7-24 d (mean 12.9 d). There were two deaths. Early open surgical drainage remains the most appropriate method of treating parapharyngeal space infections; it avoids life threatening complications with rapid recovery.

Deep neck abscesses--changing trends.

A retrospective review was conducted of 64 patients with deep neck abscesses. Based on clinical and operative findings, these abscesses were categorized as retropharyngeal abscess (29 patients), parapharyngeal abscess (10 patients), Ludwig's angina (19 patients), or necrotizing cervical fasciitis (six patients). Regional trauma from an ingested foreign body was the cause for 59 per cent of the patients with a retropharyngeal abscess. In 90 per cent of subjects with Ludwig's angina, an odontogenic cause was established; however, in the majority of cases of parapharyngeal abscess (80 per cent) and necrotizing fasciitis of the neck (85 per cent), aetiology was unknown. Fifty-five patients (86 per cent) required open neck drainage. In the remaining nine (14 per cent) endoscopic drainage of the abscess was possible. Eight patients (12 per cent) needed a tracheotomy for airway control. The overall mortality was eight per cent despite aggressive anti-microbial therapy and early surgical intervention. Thirty-four cultures grew aerobic organisms. Seventy-six per cent of these were gram-negative microorganisms. The bacteriological pattern of deep neck abscesses is changing and may be responsible for the considerable mortality rate with which the abscesses are still associated despite anti-microbial therapy.

Endoscopic management of lesions of the sella turcica.

The excellent visualization and minimally invasive surgical technique of endoscopic sinus surgery was applied to the management of 40 patients with sellar lesions. Endoscopic management of sellar lesions offers, not only the advantage of improved visualization, but also magnification, and a panoramic perspective of the important relationships of the sella turcica. In the past year, we have managed 40 subjects with sellar lesions, endoscopically: 38 patients had pituitary adenomas and two a craniopharyngioma. At our hospital, the endoscope has replaced the operating microscope for surgery for pituitary adenomas and other sellar lesions. The endoscopic approach to the sphenoid sinus and the sella is performed by an ENT surgeon and the ablative surgery performed by a neurosurgeon. Our experiences, using the endoscope to perform surgery on sellar and parasellar lesions, are reported and the advantages, over the operating microscope, which is traditionally used are discussed. The technique for endoscopic management of sellar lesions is described.

Submandibular gland excision: a five-year review.

Excision of the submandibular gland is a surgical procedure often undertaken. The procedure is the treatment of choice for patients with neoplasm of the submandibular gland and those with non-neoplastic submandibular disorders which are not controlled with conservative medical measures. Extirpation of the submandibular gland may also be undertaken for diagnostic purposes. This retrospective study of 93 consecutive patients who underwent excision of the submandibular gland in the Department of Otolaryngology, Singapore General Hospital over a five-year period was undertaken to study the indications of surgery, the pathology of the excised submandibular gland and the demographic profile of patients. Fifty-six (60.2 per cent) patients underwent submandibular gland excision for non-neoplastic salivary gland disease while 37 (39.8 per cent) had neoplastic submandibular gland disorders. The commonest pathology encountered was sialadenitis/sialolithiasis (53.76 per cent) followed by pleomorphic adenoma (33.33 per cent). Fine needle aspiration cytology (FNAC) was a valuable pre-operative investigation with a sensitivity and specificity of 94.7 per cent and 100 per cent respectively for neoplastic disease. The morbidity rate for this surgery was 4.3 per cent.

Sphenoid sinus mucocoele presenting with isolated oculomotor nerve palsy.

We describe two cases of sphenoid sinus mucocoele. Both presented with isolated oculomotor nerve palsy. Mucocoeles involving only the sphenoid sinus are uncommon. They are probably under-diagnosed as they may be asymptomatic or cause non-specific symptoms. Nasal symptoms occur infrequently but the close relationship of the sphenoid sinus to the orbital apex means that ocular symptoms including cranial nerve palsies are a common presenting feature. Involvement of the third cranial nerve in isolation is rare but has important neurosurgical implications which must be excluded before this symptom is attributed to the sphenoid sinus.

View from beneath: pathology in focus. Synovial sarcoma of hypopharynx.

Synovial sarcoma of the hypopharynx is a rare neoplasm. To date only 23 cases of synovial sarcoma of the hypopharynx have been reported in the literature. An additional case in an 18-year-old male is presented. This is the first case of synovial sarcoma in the hypopharynx to be reported in Singapore. The presentation was that of a mass in the hypopharynx; progressive dysphagia, intermittent hoarseness and gradual airway compromise. A CT scan was valuable in determining the site of origin and extent of the lesion. Histopathology was diagnostic. Treatment comprised of wide surgical excision of the tumour and post-operative radiotherapy.

Endoscopic anatomy of the sphenoid sinus and sella turcica.

An endoscopic study of the sphenoid sinus was carried out, on 30 cadavers, to understand the important anatomical relationships of the sphenoid sinus, and the sella turcica. The aim was to study the endoscopic anatomy and the variants, and to determine if endoscopic instrumentation and techniques, could play a beneficial role in endoscopic management of sellar lesions. The results of this study are discussed, with particular reference to the important surgical anatomical features of the sphenoid sinus. A surgical technique for the endoscopic transsphenoid approach to the sella turcica was developed. Anatomical variants can be identified endoscopically, and endoscopic techniques have the advantages of improved visualization, magnification, angled vision, and a panoramic perspective of the intrasphenoid anatomy, compared to currently employed methods of pituitary/sellar surgery, using the operating microscope.

Isolated sphenoethmoid recess polyps.

Isolated sphenoethmoid recess (SER) polyps are rare. They usually arise from the sphenoid sinus. We report six patients with SER polyps as the only abnormal clinical finding at initial presentation. All cases were investigated with outpatient biopsy and computed tomography (CT) or magnetic resonance (MR) imaging. Pre-operative histology revealed three cases of inflammatory disease, two cases with inverted papilloma, and one case of an ectopic pituitary adenoma arising from the sphenoid sinus. One of the inflammatory polyps arose directly from the mucosa around the sphenoid ostium. The other five cases involved the sphenoid sinus. Except for the ectopic pituitary adenoma all the polyps were managed by transnasal endoscopic surgery. We emphasize that isolated SER polyps may signify existing sphenoid pathology and a pre-operative biopsy is valuable for planning surgery.

An unusual case of sorethroat: nasopharyngeal melioidosis.

A 14-year-old Chinese female presented with severe sorethroat and swinging fever for two weeks despite one course of oral amoxycillin followed by one course of Unasyn (combination of sultamicillin, sulbactam and ampicillin). Throat swab grew Pseudomonas pseudomallel. Serology for its antibodies was very strongly positive (> 1:512). In this part of the world the IHA titre of 1:16 or greater is significant. She was successfully treated with intravenous ceftazidime. The swinging fever settled within two days. The nasopharyngeal and oropharyngeal lesions cleared after a week of therapy. A further two weeks of Ceftazidime were given to ensure a complete resolution of the infection. Oral tetracycline was given for maintenance therapy. Melioidosis involving various organs have been reported particularly pulmonary melioidosis. Nasopharyngeal melioidosis has not been reported, as far as we know. This is the first reported case.

Bronchodilator effect of terbutaline aerosol in asthmatic: comparison of two spacer devices.

The degree of bronchodilation achieved with aerosolised bronchodilators may partly depend on correct usage of a particular inhaler device. The effect of two puffs of 0.25 mg each of terbutaline aerosol using either of two spacer devices--a tube spacer and conical spacer with inhalation valve (Nebuhaler)--in a randomised manner were compared in 20 patients with bronchial asthma. All participants (11 male, 9 female) aged 16 to 50 years had clinically stable baseline airway obstruction responsive to bronchodilators. The maximum per cent increase of PEFR and FEV1 were significantly higher after inhalation via Nebuhaler than tube spacer (44.93 +/- 21.15% vs 26.67 +/- 13.17%; 74.0 +/- 17.87 vs 47.65 +/- 15.74% respectively, p less than 0.01). The increase noted at each time interval was significantly higher and more sustained with Nebuhaler. In terms of bronchodilator effect Nebuhaler had definite advantage over tube spacer in our study. There were no significant changes in pulse rate nor in blood pressure.

Retropharyngeal abscess--the foreign body connection.

Retropharyngeal abscesses have been described to be more common among children especially under the age of three or four years and oropharyngeal infection have been implicated as a common etiological factor. However, this series reveals that retropharyngeal abscesses are more commonly seen in adults in our local population. Regional trauma resulting from an ingested foreign body is the leading cause of retropharyngeal abscess in this series. Twenty-three patients seen consecutively between January 1983 and June 1989 at the Department of Otolaryngology, Singapore General Hospital were reviewed retrospectively. Factors such as age, sex, racial distribution, presenting symptoms and signs, methods used to arrive at diagnosis, therapy and complications were studied and analysed. A lateral radiograph of the neck was the single most valuable investigation in the evaluation of the retropharyngeal space. Retropharyngeal and retrotracheal width were measured in 210 normal lateral neck radiographs to establish a normal range in our population. Retropharyngeal widening greater than 5 mm and retrotracheal widening greater than 15 mm was considered significant and was noted in all 23 patients. Regional trauma resulting from an ingested foreign body was the cause of the retropharyngeal abscess in thirteen (56.5%) patients.

Migrating foreign bodies in the upper digestive tract.

Migrating foreign bodies in the aerodigestive tract are not so uncommon. Two cases of penetrating and migrating extraluminal foreign bodies in the upper aerodigestive tract are presented. Both patients had ingested fish bones. Fish bones are the commonest of bones to be ingested. Sharp and pointed fish bones are more likely to penetrate extraluminally. A high index of suspicion is necessary to institute early treatment. A CAT scan is invaluable in locating the foreign body especially with regards to surgical landmarks at exploration. Early surgical intervention avoids life-threatening complications.

Endoscopic management of cerebrospinal fluid fistulae and traumatic cephalocoele.

The excellent visualisation and atraumatic surgical techniques of endoscopic sinus surgery were applied to the management of 5 patients with cerebrospinal fluid (CSF) fistulae in the anterior skull base. The CSF fistula was iatrogenic in three patients, post-traumatic in one patient and primary in another patient. The role of endoscopes in the diagnosis and management of CSF rhinorrhoea is discussed. These five case reports illustrate the use of rigid transnasal endoscopy for diagnosis and management of CSF fistulae. The use of endoscopes allowed us to accurately localise and repair CSF fistulae. Our technique and results of endoscopic management of CSF fistulae are discussed. Using the endoscopic transnasal approach and minimally invasive techniques the fistulae were successfully repaired in all 5 patients.

Sphenoid sinus mucocele: 10 cases and literature review.

INTRODUCTION: Sphenoid sinus mucoceles represent only 1-2 per cent of all paranasal sinus mucoceles. Patients may present with a myriad of symptoms. Pre-operative investigations include nasoendoscopy, computed tomography and/or magnetic resonance imaging. Treatment is by endoscopic sinus surgery. METHODOLOGY: A retrospective review of the archives of the Singapore General Hospital otolaryngology department (1999-2006) identified 10 cases of sphenoid sinus mucocele. Patient demographics, presenting symptoms, investigations and treatment were evaluated. RESULTS: The 10 patients identified (three women and seven men) had a mean age of 54.5 years (range 24-70 years). Thirty per cent of patients had a history of nasopharyngeal carcinoma treated with radiotherapy. Presenting symptoms, in order of decreasing frequency, were: ocular symptoms (50 per cent), headaches (30 per cent), nasal discharge (30 per cent) and facial pain (10 per cent). All patients underwent pre-operative computed tomography or magnetic resonance imaging. Twenty per cent of patients had evidence of intracranial involvement on imaging. All patients underwent uncomplicated transnasal sphenoidotomy and drainage of the mucocele. There was no clinical or radiological evidence of recurrence at a mean follow up of 29 months (range 4-90 months). CONCLUSION: Sphenoid sinus mucocele is a rare condition. In this study, radiation to the head and neck appeared to be a predisposing factor, and eye symptoms were the commonest presentation. Endoscopic sinus surgery is a safe and effective treatment modality.

Ministry of Health clinical practice guidelines: Management of Rhinosinusitis and Allergic Rhinitis.

The Ministry of Health publishes national clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the Ministry of Health clinical practice guidelines on Management of Rhinosinusitis and Allergic Rhinitis, for the information of readers of the Singapore Medical Journal. Chapters, page and figure numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=24046). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.