Blue Parotid Unveiled: A Rare Case of Traumatic Hemorrhagic Parotid Lymphangioma in an Eight-Year-Old Boy.

Parotid lymphangioma is a benign lymphatic malformation commonly observed in infancy or early childhood. It often grows insidiously and presents as a painless, soft fluctuant mass. We report a case of an eight-year-old boy who was diagnosed from another center with right parotid lymphangioma of one-year duration. He presented with right painful preauricular swelling and trismus for nine days after a recent history of blunt trauma to the preauricular caused an acute expansion of the swelling and subsequently, the patient developed ipsilateral facial nerve palsy. Examination showed right preauricular swelling measuring about 6 x 6 cm that extended posteriorly until the mastoid region, superiorly until the zygoma, and inferiorly until the angle of the mandible, pushing the ear lobule anteromedially. There was bluish discoloration of the overlying skin. The swelling was warm and tender on palpation. Multiple shotty lymph nodes were palpable at the posterior triangle. Aspiration of the swelling revealed blood content, but it reaccumulated after a few hours. A magnetic resonance imaging (MRI) of the neck showed a lesion confined within the parotid gland. There was a presence of air-fluid level with dependent layers of hyperintense on the T1-weighted image (T1WI) and T2-weighted image (T2WI) with clumps of isointensity on T1WI, which are hypointense on T2WI, which is suggestive of acute-late subacute blood product. A diagnosis of lymphatic malformation complicated with hemorrhage was made. Hence, the patient underwent surgery for the evacuation of blood clot and right superficial parotidectomy. Histopathological examination of the intraoperative tissue biopsy revealed evidence of venolymphatic malformation of the parotid gland. Postoperatively, he was discharged home after three days. The facial nerve function recovered from House and Brackmann grade II to grade I three weeks after the surgery.

A Diagnostic Conundrum: Tuberculosis or Salmonella Neck Abscess?

Granulomatous neck abscesses are commonly associated with tuberculosis (TB). These chronic inflammatory reactions are rarely seen in Salmonella non-typhi (SN) infections. We report two cases of SN granuloma presenting as neck abscesses in poultry farmers. TB polymerase chain reactions (PCR) were negative. Histopathology reported necrotizing granulomatous inflammation. Salmonella species are known to cause true granulomas in bone marrow, liver, and spleen. To the best of our knowledge, true granulomas have not been described in cervical lymph nodes. The aim of this report was to highlight the importance of considering other causative microbiological agents in cases of granulomatous neck abscesses. The patients recovered after receiving treatment with surgical drainage and intravenous antibiotics.

Longitudinal outcomes for educational placement and quality of life in a prospectively recruited multinational cohort of children with cochlear implants.

OBJECTIVES: The aim of this study was to report on the educational placement, quality of life and speech reception changes in a prospectively recruited group of children after they received a cochlear implant (CI). METHOD: Data was collected on 1085 CI recipients of as part of a prospective, longitudinal, observational, international, multi-centre, paediatric registry, initiated by Cochlear Ltd (Sydney, NSW, Australia). Outcome data from children (≤10 years old) implanted in routine practice was voluntarily entered into a central, externally hosted, e-platform. Collection occurred prior to initial device activation (baseline) and at six monthly follow-up intervals up to 24 months and then at 3 years post activation. Clinician reported baseline and follow up questionnaires and Categories of Auditory Performance version II (CAP-II) outcomes were collated. Self-reported evaluation forms and patient information were provided by the parent/caregiver/patient via the implant recipient baseline and follow up, Children Using Hearing Implants Quality of Life (CuHIQoL) and Speech Spatial Qualities (SSQ-P) Parents Version questionnaires. RESULTS: Children were mainly bilaterally profoundly deaf, unilaterally implanted and used a contralateral hearing aid. Prior to implant 60% used signing or total communication as their main mode of communication. Mean age at implant was 3.2 ± 2.2 years (range 0-10 years). At baseline 8.6% were in mainstream education with no additional support and 82% had not yet entered school. After three years of implant use, 52% had entered mainstream education with no additional support and 38% had not yet entered school. In the sub-group of 141 children who were implanted at or after three years of age and were thus old enough to be in mainstream school at the three-year follow up, an even higher proportion (73%) were in mainstream education with no support. Quality of life scores for the child improved statistically significantly post implant compared to baseline and continued to improve significantly at each interval up to 3 years (p < 0.001). Parental expectation scores reduced statistically significantly from baseline compared to all intervals (p < 0.028) and then increased significantly at 3 years compared to all post baseline follow-up intervals (p < 0.006). The impact on family life was reduced post implant compared to baseline and continued to reduce between annual intervals (p < 0.001). At three years post follow up median CAP II scores were 7 (IQR 6-7) and mean SSQ-P scores were 6.8 (SD1.9) 6.0 (SD1.9) and 7.4 (SD 2.3) for speech spatial and qualities scales respectively. SSQ-P and CAP II scores improved statistically and clinically significantly compared to baseline by one year post implantation. CAP II scores continued to improve at each test interval up to three years post implant. Speech and Qualities scores improved significantly between years 1 and 2 (p < 0.001), but only the Speech scores improved significantly between years 2 and 3 (p = 0.004). CONCLUSIONS: Mainstream educational placement was achievable for most of the children, including those implanted at an older age. Quality of life for the child and the wider family improved. Future research could focus on the impact of mainstream school placement on children's academic progress, including measures of academic attainment and social functioning.

The Mysterious Whistling Breath: Foreign Body Aspiration.

Foreign body aspiration is commonly seen in the pediatric age group and can be a life-threatening condition. Typical presentations include coughing, wheezing, and choking and can often masquerade as asthma causing misdiagnosis and treatment delay. Most of the time, the actual aspiration event is unnoticed, and patients may remain asymptomatic until they present with recurrent infections with or without positive radiological findings. Aspirated objects tend to migrate distally, and organic objects may induce edema and inflammation. Diagnosis is crucial as near-total or total obstruction of the airway may cause asphyxia and, subsequently, death if no immediate intervention is taken.

A Review of Tracheal Bronchus in Universiti Kebangsaan Malaysia Medical Centre (UKMMC).

Tracheal bronchus (TB) is a rare congenital anomaly described as a abnormal bronchus that originates directly from the trachea above the carina directed towards the upper lung lobe. We analysed all paediatric rigid endoscopies of the airway from January 2015 until August 2020 to determine the incidence and characteristic of TB. In total, 68 rigid endoscopic airway examination record from children aged 0 to 12 years were analyzed. Endoscopic examination was performed from supraglottic region to carina using a 0 degree Hopkins rod lens telescope. Patients with a TB were identified and the site of TB origin was noted. Data of the identified patients was reviewed for the presence of preoperative airway findings such as stridor, upper lobe pneumonia, other congenital anomalies, intraoperative findings and complications and postoperative general condition outcome. TB was detected in 8 (11.8%) of 68 airway endoscopic examinations. 6 children (75%) were syndromic. 5 patients (62.5%) has congenital malacic airway and 2 patients (25%) has congenital tracheal stenosis. All TB originated from the right lateral wall of the trachea. All children had stridor unrelated to TB as presentation and 4 (50%) of children had preoperative upper lobe pneumonia. Tracheal bronchus is not a rare finding and is highly associated with syndromes and other airway anomalies. Although children with TB can be asymptomatic, upper lobe pneumonia is a common presentation. TB should be included in the differential diagnosis in patients with recurrent right upper lobe pneumonia or collapse and patients with unexplained oxygenation problem during endotracheal intubation, particularly in children with syndromes or other congenital anomalies.

Paediatric Adenotonsillectomy: Its Safety and Outcome in a Malaysian Tertiary Medical Center.

Adenotonsillectomy is the commonest otorhinolaryngology surgery for paediatrics. The purpose of this study was to determine the safety and outcome of adenotonsillectomy in a tertiary center in Malaysia. This was achieved by studying the demographics, indications, co-morbidities of patients and its association with the complications of the procedure. This retrospective study was conducted from November 2011 until October 2016. Medical records of patients aged 2-12 years old who had adenotonsillectomy done in our center were retrieved for data collection. A total of 143 patients who fulfilled the inclusion and exclusion criteria were recruited. Median age was 7.52 (± 2.98 SD) years old. Allergic rhinitis was the commonest co-morbidity (40%). Recurrent tonsillitis was the main indication (60%), followed by sleep disordered breathing (SDB) without apnea (29%), obstructive sleep apnea (OSA) (7%) and other indications (4%). Post-operative paediatric intensive care unit (PICU) admission was very low (1.4%) and was reserved for those with severe OSA with complications. None of the patients admitted to PICU post-operative had respiratory complications. The prevalence of post-tonsillectomy bleeding was only  2.1%. There was no significant association between patient's co-morbidity with operative complications (p = 0.269). Adenotonsillectomy is indicated for children with recurrent tonsillitis and paediatric SDB. The two most severe complications, namely post-tonsillectomy haemorrhage and respiratory complications occurred but incidence was low. Criteria of post-operative PICU or paediatric high dependency unit admission for paediatric SDB has to be based on multiple clinical and logistics factors and not only patients co-morbidity and indication of surgery.

Pediatric Langerhans Cell Histiocytosis: An Aggressive Presentation.

Encountering a young child with an enlarging painless facial swelling often raises concerns in the treating physician about the possibility of a congenital lesion or an unfavorable pediatric tumor. We discuss a case of a female child who presented with multiple craniofacial swellings, which turned out to be Langerhans cell histiocytosis (LCH). She was subsequently diagnosed with multisystem LCH (MS-LCH) with risk-organ involvement, which included the craniofacial bones, skin, hemopoietic system, and liver. We analyze the various presentations and systemic complications of this rare pediatric tumor, LCH, with an aim to address the diagnostic dilemma associated with this great masquerader.

Case series of tuberculous otitis media: Spectrum of clinical presentation and outcome.

OBJECTIVE: Tuberculous otitis media (TB OM) is a rare disease. We present here our experience of TB OM on its clinical presentation, investigation and treatment outcome. METHODS: A retrospective observational study was performed and clinical data of patients in whom TB OM was diagnosed at our center between 2008 and 2019 was analyzed. RESULTS: Five cases of TB OM were identified. Otorrhoea was the most consistent presenting chief complaint while one of the cases presented with right post-auricular swelling. All the cases were successfully treated with anti-tuberculous medication with outcome of dry middle ear but only one case achieved full recovery of hearing loss. CONCLUSION: Due to the disparity of presentations in all our patients, we would like to emphasize the high index of suspicion of TB OM in acute or chronic cases of otitis media with unusual presentation or poor response to standard treatment.

Where are the vesicles? A case report of Ramsay Hunt syndrome.

A 1-year-10-month-old child developed left-sided Ramsay Hunt syndrome (RHS) without vesicles 1 month after an episode of varicella zoster infection. No ear symptoms, including hearing loss, tinnitus, or imbalance, were reported. The external ear and otoscopic examinations were unremarkable. He achieved adequate recovery with corticosteroid treatment. This case report discusses the unusual presentation of RHS without vesicles, the diagnostic dilemma in young children, varicella zoster virus hepatitis, treatment modalities, and the role of vaccination in its prevention.

Serie de casos de otitis media tuberculosa: espectro de presentación clínica y resultado / Case series of tuberculous otitis media: Spectrum of clinical presentation and outcome

Objective: Tuberculous otitis media (TB OM) is a rare disease. We present here our experience of TB OM on its clinical presentation, investigation and treatment outcome. Methods: A retrospective observational study was performed and clinical data of patients in whom TB OM was diagnosed at our center between 2008 and 2019 was analyzed. Results: Five cases of TB OM were identified. Otorrhoea was the most consistent presenting chief complaint while one of the cases presented with right post-auricular swelling. All the cases were successfully treated with anti-tuberculous medication with outcome of dry middle ear but only one case achieved full recovery of hearing loss. Conclusion: Due to the disparity of presentations in all our patients, we would like to emphasize the high index of suspicion of TB OM in acute or chronic cases of otitis media with unusual presentation or poor response to standard treatment. (AU)

Objetivo: La otitis media tuberculosa (TB OM, por sus siglas en inglés) es una enfermedad infrecuente. Presentamos nuestra experiencia sobre la misma en cuanto a presentación clínica, investigación y resultado del tratamiento. Métodos: Se realizó un estudio retrospectivo observacional, analizándose los datos clínicos de los pacientes a quienes se diagnosticó de TB OM en nuestro centro entre 2008 y 2019. Resultados: Se identificaron 5 casos de TB OM, siendo otorrea la forma de presentación más consistente, mientras que uno de los casos presentó edema postauricular derecho. Todos los casos fueron exitosamente tratados con fármacos anti-tuberculosos con resultado de oído medio seco, aunque un caso logró la recuperación total de la hipoacusia. Conclusión: Debido a la disparidad de las presentaciones en todos nuestros pacientes, nos gustaría resaltar el elevado índice de sospecha de TB OM en casos agudos o crónicos de otitis media con presentación inusual o mala respuesta al tratamiento estándar. (AU)

Spectrum of upper airway pathology in children with Down syndrome in a single tertiary centre.

BACKGROUND: Down syndrome (DS) is the most common human chromosomal genetic disorder; caused by extra copy of chromosome 21-one out of 792 babies globally and one in 950 in Malaysia. OBJECTIVES: To obtain spectrum of upper airway pathology in DS children-prevalence, causes and management practices. MATERIALS AND METHODS: A cross-sectional study of children with DS aged less than 18 years old with signs of UAO was conducted. Diagnosis of UAO, management and final outcome was observed and documented. RESULTS: Ninety-one patients were recruited. 20 cases (22%) had significant noisy breathing which indicates the prevalence of upper airway pathology (p=.025). Laryngomalacia (34.5%) was the most common pathology, followed by paediatric SDB (24.1%), tracheal bronchus (17.2%), tracheal stenosis (6.9%), and tracheomalacia (6.9%). Seven cases (7.7%) presented with respiratory distress. 12 cases were managed conservatively, while eight cases required further investigations under general anaesthesia (GA) with/without surgical intervention. Six cases showed symptoms resolution within a week post-surgical intervention, and another case resolved after 30 days and one case resolved after 8 months of post-surgical intervention. CONCLUSION AND SIGNIFICANCE: Early detection and high index of suspicion is required to diagnose and treat these anomalies timely.

Tracheal cartilaginous sleeve in Pfeiffer syndrome: lesson learnt from its rarity.

Pfeiffer syndrome is a rare inherited craniofacial disorder. Upper airway obstruction is common among patients with Pfeiffer syndrome due to craniosynostosis. They may also present with lower respiratory tract obstruction due to a rare congenital airway malformation called tracheal cartilaginous sleeve (TCS). We report the case of a patient with Pfeiffer syndrome who presented with recurrent bronchopneumonia, discovered incidentally to have TCS via direct visualisation during tracheostomy. Relevant literature for this rare clinical condition are reviewed and discussed. Clinicians should be aware of TCS when encountering patients with craniosynostosis who present with recurrent lower respiratory tract infections. Careful and meticulous investigations should be performed to look for TCS, especially in patients with craniosynostosis.

Postcricoid haemangioma with laryngomalacia in infancy.

Infantile haemangioma represents a congenital vascular anomaly commonly observed in the head and neck region. Such an occurrence over the postcricoid region, however, is rather unusual. Herein, the authors report a case of a synchronous postcricoid haemangioma in a 7-week-old newborn diagnosed with severe laryngomalacia. In addition to the floppy redundant arytenoid mucosa, flexible laryngoscopy revealed a lobulated bluish mass at the postcricoid. The lesion was hyperintense on T1-weighted sequence and was enhanced with contrast, supporting the diagnosis of a haemangioma. She underwent surgical excision of the haemangioma with intralesional steroid injection. Surveillance at 6-month postoperation did not show disease recurrence.

Challenges faced by parents when seeking diagnosis for children with sensorineural hearing loss.

INTRODUCTION: The Joint Committee of Infant Hearing (JCIH) recommended hearing screening by one month of age, diagnosis of hearing loss by three months of age, and intervention initiated by six months of age. In Malaysia however, the age of diagnosis of hearing loss in children is relatively late. This study aimed to identify the challenges faced by parents in seeking a diagnosis of hearing loss for their children. METHOD: The study utilized a semi-structured interview with open-ended questions to obtain information about parents' experiences during the diagnosis period and their challenges when going through that process. In this study, a total of 16 parents of children who were diagnosed with moderate to profound sensorineural hearing loss and received intervention within three years at the time of the study participated. Ten of the children were cochlear implant users, and six were hearing aid users. RESULTS: Thematic analysis was used to analyse themes generated from the data according to the study objective. Four main themes and 17 subthemes were identified from this study. The four main themes were 1) Parents' emotion; 2) Parental knowledge; 3) Others; 4) Profesional services. Challenges that parents faced often include emotional behaviours such as feeling guilty and devastated during the diagnosis, lack of information-sharing from healthcare givers, lack of knowledge on childhood hearing loss among parents, support from families, seek for a second opinion, worry about others' acceptance, longer time for diagnosis to confirm, late referral to other related profesionals and no priority for the appointment. CONCLUSION: Emotion is identified as the biggest challenge faced by parents in the process of diagnosis for their children with hearing loss. Hence, management of parental emotion needs to be emphasized by health profesionals as it influences the acceptance of parents towards their child's diagnosis.

Case series of tuberculous otitis media: Spectrum of clinical presentation and outcome.

OBJECTIVE: Tuberculous otitis media (TB OM) is a rare disease. We present here our experience of TB OM on its clinical presentation, investigation and treatment outcome. METHODS: A retrospective observational study was performed and clinical data of patients in whom TB OM was diagnosed at our center between 2008 and 2019 was analyzed. RESULTS: Five cases of TB OM were identified. Otorrhoea was the most consistent presenting chief complaint while one of the cases presented with right post-auricular swelling. All the cases were successfully treated with anti-tuberculous medication with outcome of dry middle ear but only one case achieved full recovery of hearing loss. CONCLUSION: Due to the disparity of presentations in all our patients, we would like to emphasize the high index of suspicion of TB OM in acute or chronic cases of otitis media with unusual presentation or poor response to standard treatment.

Retropharyngeal Abscess in a Neonate After Extravasation Injury: To Drain or not to Drain?

Neonatal retropharyngeal abscess (RPA) is a rare and life-threatening entity. Most of the cases are idiopathic in nature. We encountered a case of RPA in a newborn secondary to extravasation injury. The presence of neck swelling with clinical deterioration following extravasation of total parenteral nutrition (TPN) infused via a peripherally inserted central catheter at the right upper limb raised the suspicion of neck abscess. This was later confirmed to be RPA based on magnetic resonance imaging of the neck. She was treated with prolonged intravenous antibiotics in the Neonatal Intensive Care Unit (NICU). Her condition gradually improved, evidenced by resolution of the collection on serial imaging. Early recognition and prompt management are crucial to reduce the morbidity and mortality from RPA.

Intermittent Suprasternal Neck Mass Caused by Herniation of Ectopic Thymus: Report of Two Cases.

INTRODUCTION: Ectopic thymus is an uncommon cause of neck masses in children that frequently present as lateral cervical swelling especially on the right side. CASE REPORT: We report two cases with atypical clinical presentation of ectopic thymus and superior herniation of normal thymus. Both of the patients manifested as intermittent midline mass at the suprasternal region during Valsalva manuevre. Unique ultrasound features with the location along the thymic descent together with dynamic assessment of the organ movement were essential to reach the correct diagnosis. Conservative approach was considered in these patients considering the necessity of thymus in the process of puberty. CONCLUSION: High index of suspicion is of utmost importance when encounter patient with similar clinical manifestation to avoid unnecessary diagnostic modalities and surgeries. Accurate diagnosis will also alleviate parents' anxiety.

Surgical management of cochlear implant in chronic otitis media patients: safe and sound.

INTRODUCTION: Cochlear implantation (CI) in cases with chronic otitis media (COM) was previously contraindicated but recent advances have made it possible. OBJECTIVE: To review surgical and audiological outcomes of COM patients that underwent CI. MATERIAL AND METHODS: Retrospective review of patients above 18 years old. RESULTS: Ten patients with complete data were included. Patients were aged 24-69 years old. Tympanoplasty and mastoidectomy were performed before CI. Imaging was performed to rule out ossifications. Eight patients underwent a standard canal wall up with either cochleostomy or round window approach. One patient had additional canalplasty and tympanoplasty and another one had blind sac procedure respectively. Analysis of the hearing aided level with CI and hearing aid showed significant benefit provided by the CI (Z = 2.803, p = .005). DISCUSSION: Creating a dry and safe ear is important prior to CI. Definite hearing improvement is seen in all our cases that helped them to become independent again in their daily life. Hearing aid usage pre-CI might not be important as the hearing aids may continue to cause discharging ears and the benefits of hearing aids in severe to profound hearing loss are very minimal. CONCLUSIONS: Cochlear implant is safe and effective in COM patients.

The outcomes of bilateral cochlear implant users in Universiti Kebangsaan Malaysia.

INTRODUCTION: Bilateral cochlear implants are seen to improve hearing capabilities. OBJECTIVE: To assess the auditory outcome of paediatric bilateral cochlear implant in Universiti Kebangsaan Malaysia. MATERIALS AND METHODS: This was a cross-sectional and descriptive study single centre analysis. Categories of Auditory Performance (CAP-II) scale and Speech, Spatial and Qualities (SSQ) of Hearing questionnaire were used. RESULTS: Forty-six patients were recruited. Majority of the children (30.4%) rated 7 and 23.9% scored perfectly (9) based on the CAP-II Scale. The least performing children were rated 5 (average). Children that were implanted sequentially within 24 months showed median CAP-II scale of 7. No significant correlation seen between CAP-II and the duration interval, use and age of 1st CI (p > .05). The speech domain of SSQ-P scale showed median value of 8 indicating good speech understanding. The spatial hearing domain had median value of 7, quality of hearing domain had median of 8. Significant correlation seen in hearing in noise with the duration of use of CI (p < .05). DISCUSSION: Bilateral CI have shown benefits in auditory performance even though majority were performed sequentially. Promising outcome was better with prolonged usage of the device. CONCLUSION: Hearing in noise is significantly better in bilateral CI.

Myeloid Sarcoma of Temporal Bone: A Rare Manifestation of Relapse Acute Myeloid Leukemia.

Myeloid sarcoma is a rare malignant extramedullary neoplasm of myeloid precursor cells. This disorder may occur in concomitance with or precede development of acute or chronic myeloid leukemia. Sometimes, it is the initial manifestation of relapse in a previously treated acute myeloid leukemia. We report a case of 11 years old boy with acute myeloid leukemia in remission state, presented with short history of right otalgia associated with facial nerve palsy. Diagnosis of right acute mastoiditis with facial nerve palsy as complication of acute otitis media was made initially. Patient underwent simple cortical mastoidectomy but histopathology from soft tissue that was sent revealed diagnosis of myeloid sarcoma. A leukemic relapse was confirmed by paediatric oncologist through bone marrow biopsy. Chemotherapy was commenced but patient responded poorly to the treatment.