Rhinoplasty Surgical Technique for Nasal Dermoid Cyst Removal in Adult: Case Report.

Nasal dermoid cyst is a rare benign lesion. The mainstay of treatment for a nasal dermoid cyst is surgical excision, which aims to remove the cyst and associated structures to prevent recurrence. We report a case of a 30-year-old man with nasal dermoid cyst, without intranasal or intracranial extension. The patient underwent open rhinoplasty technique for dermoid cyst excision. He had an uneventful postoperative recovery and was discharged well. The cyst and associated structure were successfully removed. There was no evidence of recurrence and complications postoperatively after 2 years of follow-up.

Orbital Apex Syndrome Secondary to Huge Primary Ethmoidal Sinus Mucocele: A Case Report.

Ethmoidal sinus mucoceles are benign expansile lesions that may progressively invade the orbit causing optic nerve compression and its nearby structures. We report a rare case of primary ethmoidal sinus mucocele instigating orbital apex syndrome. A 40-year-old man presented with right eye (RE) progressive blurring of vision with diplopia for 2 weeks. It was preceded by right-sided facial pain for 3 months. Clinical examination revealed RE proptosis with multiple cranial nerves palsy involving right cranial nerves II, III, IV, V, and VI, suggestive of right orbital apex syndrome. Magnetic resonance imaging (MRI) demonstrated right eye proptosis and right ethmoidal mucocele with intracranial and right intraorbital extension compressing the right medial rectus and optic nerve. The patient underwent an uncomplicated endoscopic sinus surgery resulting in a return to normal appearance and function post-operation. Thus, ethmoidal mucoceles are benign and curable with early recognition and intervention.

Clinical students' reflections on the preclinical anatomy learning experience.

Objectives: Anatomy is a fundamental pillar of medical knowledge that bridges basic medical science knowledge and clinical practice. However, integrated modern medical curricula have reduced the anatomy teaching content, and cadaveric dissection is no longer conducted. Medical graduates who lack anatomy knowledge are anticipated to be inadequately equipped for safe clinical practice. This study was aimed at exploring clinical year students' experiences regarding their anatomy learning during the preclinical phase in Malaysian medical schools. The findings reflect how the students' preclinical anatomy training prepared them for their clinical years of study. Methods: A qualitative phenomenology study using the focus group discussion method was conducted on 30 final-year students from four public universities. Four focus group discussion sessions were conducted, and students' responses were transcribed and converted to electronic formats. The transcripts were analyzed thematically with ATLAS.ti software. Results: The first-cycle coding of the text analysis generated 157 open codes based on the phrases used by the participants. The subsequent coding cycle produced 16 axial codes-groups of open codes with similar features. During the final coding cycle, the content and interrelations between the axial codes were categorized into six codes: (1) preclinical anatomy learning experience, (2) anatomy content and teaching, (3) anatomy-related competency, (4) the importance of anatomy knowledge in clinical practice, (5) the importance of early exposure to applied clinical anatomy, and (6) suggestions for future anatomy education. Conclusions: The six identified themes reflected students' perceptions of their anatomy learning experience, the challenges that they faced during their preclinical years, and their opinions regarding the anatomy knowledge and skills that are functionally relevant during the clinical years. Their responses also echoed the need to improve anatomy teaching and learning, thereby emphasizing the importance of early clinical integration and application.

Primary Nasopharyngeal Tuberculosis: A Diagnostic Challenge.

Introduction: Primary nasopharyngeal tuberculosis (NPTB) is a rare disease but should not be missed as one of the differential diagnoses for cervical lymphadenopathy or nasopharyngeal mass. Case Report: We describe a case of a 38 year old lady, who presented with bilateral cervical lymphadenopathy associated with intermittent fever. Nasoendoscopy examination and computed tomography scan of the neck revealed a centrally located mass predominantly at the left posterior nasopharyngeal wall without obliteration of both fossae of Rosenmuller. Typical histopathological features of necrotizing granulomatous lymphadenitis together with the common clinical presentation of cervical lymphadenopathy and nasoendoscopy findings of nasopharyngeal mass conclude the diagnosis of nasopharyngeal tuberculosis. With anti-tuberculous therapy, the cervical lymphadenopathy and nasopharyngeal mass were completely resolved. Conclusion: Nasopharyngeal tuberculosis is an uncommon disease with great diagnostic challenges and with early diagnosis and adequate treatment, NPTB carries a good prognosis with complete disease resolution.

Series of isolated sphenoid disease: Often neglected but perilous.

Isolated sphenoid sinus disease (ISSD) is an uncommon entity and may present with non-specific symptoms. As sphenoid sinus is located adjacent to vital structures, a diseased sphenoid sinus can potentially lead to devastating complications such as cranial neuropathies, cavernous sinus thrombosis and intracranial abscess. Herein, we report a case series of three patients who presented with different localization of headache as their main symptom. Endoscopic nasal assessment showed abnormal nasal cavity findings with mucosal thickening and soft tissue mass occupying the sphenoid sinus revealed by computed tomography (CT) scan. All the sphenoid sinuses were drained via endoscopic approach. Post operatively, antibiotics or anti-fungal were given, however, these three cases displayed the possible variation in severity of this disease. Case 1 had an uncomplicated inflammatory disease of the sphenoid sinus, which is of bacterial origin, while the other two cases had fungal infection. Case 2 achieved disease stability with anti-fungal treatment, but Case 3 had a serious complication after treatment with permanent vision loss. A patient who presents with atypical headache, not responsive to analgesia should be investigated promptly with nasal endoscopic examination and radiological imaging for isolated sphenoid sinus disease to avoid devastating complications.

The Effectiveness of Budesonide Nasal Irrigation in Patients with Allergic Rhinitis.

Background: Allergic rhinitis (AR) is a long-standing disease and has been shown to cause significant impairment in patients' quality of life. Saline nasal irrigation is a proven adjunct in the treatment of AR. The addition of steroid to the saline solution can provide local steroid effect and increase the effectiveness of this technique. Our study aimed to determine the effectiveness of budesonide nasal irrigation as an adjunct to the treatment of AR, compared with saline nasal irrigation. Methods: This was a randomised controlled study involving 99 patients diagnosed with AR, half of whom were treated with saline nasal irrigation and the other half with budesonide nasal irrigation. Parameters measured include the Sino-Nasal Outcome Test (SNOT-22) questionnaire, endoscopic nasal examination findings and blood eosinophil count. Results: Patients treated with budesonide nasal irrigation had significant improvement in total SNOT-22 score (P < 0.001) and improvement in the endoscopic nasal examination findings, such as nasal mucosa oedema and secretions (P < 0.001). However, there was no significant improvement of blood eosinophil count in patients treated with either budesonide or saline nasal irrigation. Conclusion: Budesonide nasal irrigation is effective as an adjunct in the treatment of AR.

The prevalence of complementary and alternative medicines (CAM) usage among allergic rhinitis patients in Malaysia.

PURPOSE: We conducted this study to estimate the prevalence of complementary and alternative medicines (CAM) usage among allergic rhinitis (AR) patients in Malaysia and understand the practice of CAM usage among them. We also included a literature review on the commonly used CAM for AR. METHODS: A cross-sectional study which included a questionnaire-based study and information of allergic rhinitis from patient's clinic records. Patients with AR who attended the ORL-HNS department in Hospital Universiti Sains Malaysia and Hospital Sultanah Aminah, Malaysia were enrolled after consented, on a first-come first-serve basis as convenience sampling from July 2020 until February 2021. A pre-tested self-administered, 16-item questionnaire in Malay language was distributed to the participants. The questionnaire consists of a set of 16 questions with subsets to enquire about the sociodemographic data and pattern of usage of CAM and its effectiveness. RESULTS: 372 patients were enrolled in this study consisting of 217 (58.3%) female and 155 (41.7%) male patients. 231 (62.1%) participants had used CAM for AR in the past 10 years. A higher proportion of females (p = 0.015) and those with higher income (p = 0.004) had used CAM. Among the users, 87.9% found CAM to be effective. No differences were found in terms of age (p = 0.888) and education level (p = 0.057) for CAM usage. CONCLUSION: CAM is widely used in Malaysia to alleviate AR symptoms, with a large proportion of users think it is effective. Therefore, more researches should be conducted to provide evidence and guidance to integrate CAM into AR management.

A rare case of sinonasal solitary fibrous tumour in a patient with concurrent papillary thyroid carcinoma: A case report.

INTRODUCTION AND IMPORTANCE: A solitary fibrous tumour (SFT) is a rare neoplasm that commonly arises in the pleura and can occur in other extrathoracic sites. Extrapleural SFT, particularly in the sinonasal cavity, is extremely rare. There are no definite diagnostic criteria for sinonasal SFT as it is rare. Histologic analysis with immunohistochemistry plays an important role in diagnosing SFT. CASE PRESENTATION: We report herein a case of SFT of the sinonasal cavity, which later spread to the oral cavity in a 67-year-old male with underlying papillary thyroid carcinoma (PTC) stage IV. He complained of recurrent epistaxis from a mass in his left nasal cavity for two weeks. The mass grew bigger, and spread to the oral cavity, causing dysphagia and upper airway obstruction. Tracheostomy was done under local anaesthesia and a biopsy of the mass was taken to rule out metastasis from the PTC. However, histopathological examination revealed a mesenchymal tumour of fibroblastic type, consistent with an SFT. He was planned for surgical resection of the tumour. However, he refused the operation and was lost to follow-up. CLINICAL DISCUSSION: We describe the clinical presentation of this rare tumour of the sinonasal and oral cavity, including upper airway obstruction, and the importance of immunohistochemical markers such as CD34 and BCL-2 in diagnosing SFT. Complete resection of the tumour is the definitive treatment for SFT. CONCLUSION: SFT of the sinonasal and oral cavity is extremely rare. Upper airway obstruction may occur due to the location of the tumour in the airway region. Immunohistochemistry is crucial to distinguish this tumour from other mesenchymal tumours.

Closing the knowledge gap in Malaysian pharmacists: a virtual Allergic Rhinitis Boot Camp initiative.

BACKGROUND: In primary care, general practitioners (GPs) and pharmacists are at the frontline to identify, classify and manage patients suffering from allergic rhinitis (AR). The Allergic Rhinitis and its impact on Asthma (ARIA) guidelines aid clinicians in disease management by providing evidence-based recommendations. A recently published ASEAN primary care survey demonstrated that the awareness of ARIA guidelines was high among GPs but notably lower in pharmacists. Hence, this study seeks to evaluate the effectiveness of a Boot Camp education initiative in bridging the unmet needs in pharmacist awareness and education. METHODS: The boot camp was organised as a virtual event. The participants answered the same questionnaire before (pre-assessment) and immediately after (post-assessment) the boot camp session. Statistical analysis was performed on the data paired between the pre- and post- assessments using SPSS v. 25.0 software. RESULTS: The boot camp survey results showed that second-generation oral antihistamines and allergen avoidance are the most preferred options for AR treatment in pharmacy practice, irrespective of the disease severity. In both pre- and post-assessments, efficacy was ranked as the most important factor considered for choosing an antihistamine and which affects patient adherence. With the boot camp initiative, there was a statistically significant increase in awareness about the patient profiling tool (from 31.6% to 88.2%) and ARIA guidelines (from 40.4% to 91.2%) among the pharmacists (p<0.05). The proportion of pharmacists who were able to identify, classify and refer AR patients was significantly increased in post-assessment (p<0.05). Post the boot camp, among the proportion of pharmacists (91.2%) who were already aware of ARIA, a high percentage of them further agreed that ARIA guidelines were useful in identifying and treating patients with AR, as well as classifying AR, respectively (97.6%, 95.2%, and 93.5%). CONCLUSIONS: Based on improvements in knowledge and understanding of disease management post assessment, the Allergic Rhinitis Boot Camp initiative is effective and relevant to pharmacy practice. Outreach programs like this reiterate the emphasis on patient compliance and importance of utilizing ARIA guidelines in pharmacy practice that facilitates better management of AR in primary care.

Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction.

OBJECTIVE: Patients suffering from persistent inferior turbinates hypertrophy refractory to medical treatments require surgical intervention where the main aim is symptomatic relief without any complications. Extraturbinoplasty is one of the preferred procedures for turbinate reduction due to its efficacy in freeing up nasal space by removing the obstructing soft tissue and bone while preserving the turbinate mucosa. We sought to evaluate the effectiveness and safety of microdebrider assisted turbinoplasty (MAT) and coblation assisted turbinoplasty (CAT) performed as an extraturbinoplasty procedure. METHODS: A prospective randomized comparative trial was conducted among patients with bilateral nasal blockage secondary to inferior turbinates hypertrophy. Patients were randomly assigned to MAT or CAT. An extraturbinal medial flap turbinoplasty was performed for both techniques. Symptom assessment was based on the visual analogue score for nasal obstruction, sneezing, rhinorrhea, headache and hyposmia. Turbinate size, edema and secretions were assessed by nasoendoscopic examination. The assessments were done preoperatively, at 1st postoperative week, 2nd and 3rd postoperative months. Postoperative morbidity like pain, bleeding, crusting and synechiae were documented. The clinical outcomes of both techniques were analyzed using repeated measures ANOVA. RESULTS: A total of 33 participants were recruited, 17 patients randomized for MAT and 16 patients for CAT. Nasal obstruction, discharge, sneezing, headache and hyposmia significantly reduced from 1st week until 3 months for both procedures. Similar significant reductions were seen for turbinate size, edema and secretions. However, there was no significant difference in symptoms and turbinate size reduction were seen between both groups at the first postoperative week, 2nd and 3rd postoperative months. There was significant longer operating time for CAT when compared to MAT (p = 0.001). The postoperative complications of bleeding, crusting and synechiae did not occur in both groups. CONCLUSION: Both MAT and CAT were equally effective in improving nasal symptoms and achieving turbinate size reduction in patients with inferior turbinate hypertrophy. Both MAT and CAT offer maximal relieve in patients experiencing inferior turbinates hypertrophy by removing the hypertrophied soft tissue together with the turbinate bone without any complications.

Tualang honey versus steroid impregnated nasal dressing following endoscopic sinus surgery: a randomized controlled trial.

OBJECTIVES: Recurrence rate of nasal polyps is high following endoscopic sinus surgery. To improve the surgical outcome, steroid impregnated nasal dressing is used postoperatively We aimed to compare the effect of Tualang honey impregnated nasal dressing with steroid impregnated nasal dressing on wound healing and surgical outcomes in post endoscopic sinus surgery patients. METHODS: A prospective, randomized, controlled trial was carried out at two tertiary hospitals. 32 patients diagnosed with chronic rhinosinusitis and had underwent endoscopic sinus surgery were enrolled. The study group received 2 mL of Tualang honey nasal dressing and the control group received nasal dressing with 2 mL of triamcinolone 20 mg/mL as positive control. A 2 cm nasal dressing was placed longitudinally into the middle meatuses of both nasal cavities. Postoperative healing assessments of edema, crusting, secretions, scarring and symptoms were performed at postoperative day 7, 14, 28 and at 3 months using Sinonasal Outcome Test 22 questionnaire and modified Lund-Kennedy scoring system. RESULTS: There were no significant differences noted in the scores of Sinonasal Outcome Test 22 and modified Lund-Kennedy at Day 7, 14 and 28 (p>0.05) for both groups. At 3rd month, patients in the triamcinolone group had lesser symptoms and better endoscopic findings (p<0.05). CONCLUSION: Tualang honey is not as effective as steroid in achieving good wound healing and surgical outcomes in post endoscopic sinus surgery patients. Thus, it is not suitable as a substitute for steroid to reduce symptoms and prevent recurrence of disease.

Tear cytokine levels in allergic rhinitis without ocular symptoms.

OBJECTIVE: To compare cytokine levels in the pre-corneal tear film between patients with allergic rhinitis, allergic rhinoconjunctivitis and the normal population. DESIGN: A comparative cross sectional study. PARTICIPANTS: Patients were divided into Group 1 (allergic rhinitis without conjunctivitis), Group 2 (allergic rhinoconjunctivitis), and Group 3 (normal population). METHODS: A comparative cross-sectional study was conducted. Patients were divided into; Group 1 (allergic rhinitis without conjunctivitis), Group 2 (allergic rhinoconjunctivitis), and Group 3 (normal controls). Tears were collected using Schirmer strips and cytokine analysis performed using enzyme linked immunosorbent assay. RESULTS: There were a total of 68 subjects. Median values of cytokines in the allergic rhinitis group were as follows; TNFa (45.34 pg/ml), IL-4 (61.91 pg/ml), IL-5 (8.92 pg/ml), IL-6 (538.37 pg/ml) and IL-8 (1438.72 pg/ml). Cytokine levels in the group with allergic rhinoconjunctivitis were approximately two-fold higher than in the group with allergic rhinitis only. The median cytokine level in the control group was lowest. A significant inter-group difference was observed for TNF-alpha, IL-4, IL-6 and IL-8 levels, with allergic rhinoconjunctivitis patients demonstrating significantly elevated cytokines compared to those with allergic rhinitis only (p<0.001). These four cytokines were also significantly higher in those with allergic rhinitis than in controls (p<0.005). Although the group with allergic rhinoconjunctivitis had the highest levels of IL-5, no statistically significant inter-group difference was noted (p=0.479). CONCLUSION: This study demonstrated the presence of raised tear film inflammatory cytokines even in allergic rhinitis patients without ocular symptoms. These patients may be at increased risk of developing allergic conjunctivitis. These findings not only substantiate the immunological theory of the naso-ocular reflex, but have clinical and therapeutic implications for the holistic management of allergic rhinitis and conjunctivitis.

Mesenchymal chondrosarcoma of maxilla in paediatric patient.

Chondrosarcoma (CS) is a malignant tumour of long and flat bone characterised by the formation of cartilage. Mesenchymal chondrosarcoma (MCS) is a rare subtype of CS that is more aggressive and may lead to erroneous diagnosis in a limited biopsy. The diagnosis is mainly based on the histopathological appearance of biphasic pattern of undifferentiated small round cells separated by islands of well-differentiated hyaline cartilage. We report a case of 13-year-old boy who initially presented with gum swelling and the biopsy result suggested a benign fibrous lesion. Following an extensive lesion shown in radiologic findings, the tumour excision was done and finally was diagnosed as an MCS of the maxilla. The patient was given postoperative chemotherapy (EURO-EWING 99 regimen), and now on regular follow-up for monitoring of local recurrence or tumour metastasis.

A computed tomographic analysis of frontal recess cells in association with the development of frontal sinusitis.

OBJECTIVE: This study was done to determine frontal recess anatomy cell variations and its association with frontal sinusitis. The incidence of frontal recess cells in the population, the presence of frontal recess cell variations in chronic rhinosinusitis and non-chronic rhinosinusitis and the association of frontal recess cell variation in the development of frontal sinusitis were also assessed. METHODS: This was an observational, retrospective cross-sectional study of computed tomography (CT) scan of paranasal sinus that had been performed on patients in Hospital Universiti Sains Malaysia and Hospital Sultanah Bahiyah done from January 2009 until December 2016. The presence of frontal recess cells variation was compared with other populations. RESULTS: A total of 312 sides from 156 patients' CT scan images were analyzed. Left and right sinuses were considered individually. A total of 63 sides showed evidence of frontal sinusitis, 37 were male and 26 were female, whereas 249 sides were clear from frontal sinus disease. It was not much difference in mean age for frontal sinusitis patient (46.51±14.00) and patients without frontal sinusitis (48.73±16.44). The percentage was almost equal for CRS and non-CRS groups regardless of side and gender. In our study, the frontal recess cell such as agger nasi cell was found in almost all patients 98.1%, frontal ethmoidal cell type 1, type 2, type 3 and type 4 comprised of 28.8%, 31.1%, 14.4% and 0% respectively. Whereas, suprabullar cell can be seen in 40.3%, supraorbital ethmoid cells 16.7%, frontal bullar cell 33.0% and inter-frontal sinus septal cells 10.8%. There was a statistically significant association between the presence of frontal bullar cell and the development of frontal sinusitis (p value<0.001). CONCLUSION: The frontal recess cells variation in Malaysian subjects were almost similar to those reported in other Asian populations such as Japanese, Taiwanese, Chinese and Korean. Our study found that frontal bullar cells had a significant association with the development of frontal sinusitis than other frontal recess cells. The understanding of the frontal recess anatomical structures was very important as this would lead to a successful treatment of CRS and at the same time it helped the surgeon to have a better plan of endoscopic sinus surgery to prevent the disease recurrence and surgical complication.

A Study of Single Nucleotide Polymorphisms of Tumour Necrosis Factor α-1031 And Tumour Necrosis Factor ß+ 252 in Chronic Rhinosinusitis.

OBJECTIVES: This case-controlled study aimed to identify the association of tumor necrosis factor (TNF)α-1031 and TNFß+ 252 gene polymorphisms between chronic rhinosinusitis (CRS) and healthy controls. Another purpose of this study was to investigate the associations of these gene polymorphisms with factors related to CRS. METHODS: All deoxyribonucleic acid (DNA) samples were genotyped for TNFα-1031 and TNFß+252 genes by mean of polymerase chain reaction (PCR) and restriction fragment length polymorphisms (RFLP). The statistical analysis were carried out using chi-square test or Fisher exact test to determine the associations of these gene polymorphisms in CRS. Multiple logistic regression was performed to evaluate the associations of these gene polymorphisms in CRS and its related risk factors. RESULTS: The genotype and allele frequencies of TNFα-1031 and TNFß+252 gene did not show any significant associations between CRS and healthy controls. However, a significantly statistical difference of TNFα-1031 was observed in CRS participants with atopy (P-value, 0.045; odds ratio, 3.66) but not in CRS with asthma or aspirin intolerance. CONCLUSION: Although the presence of TNFα-1031 and TNFß+252 gene polymorphisms did not render any significant associations between CRS and healthy control, this study suggests that TNFα-1031 gene polymorphisms in CRS patients with atopy may be associated with increase susceptibility towards CRS.