An 8-year-old girl was noticed by her parents to be less attentive and she would respond only after being called several times. She had just recovered from an upper respiratory tract infection two weeks before. The parents brought her to see a primary care physician. The patient had no other complaints, and the rest of the history was unremarkable. Physical examination was normal except for the otoscopic findings shown below (Figure 1) Tuning fork tests indicated conductive deafness.
Sleeve gastrectomy, gastric bypass, gastric banding, and duodenal switch are the most common bariatric procedures performed worldwide. Ninety-five percent of bariatric operations are performed with minimally invasive laparoscopic technique. Perioperative morbidities and mortalities average around 5% and 0.2%, respectively. Long-term weight loss averages around 15% to 25% or about 80 to 100 lbs (40-50 kg). Comorbidities, including type 2 diabetes, hypertension, dyslipidemia, sleep apnea, arthritis, gastroesophageal reflux disease, and nonalcoholic fatty liver disease, improve or resolve after bariatric surgery.
Metabolic surgery is increasingly becoming recognized as a more effective treatment for patients with type 2 diabetes (T2D) and obesity as compared to lifestyle modification and medical management alone. Both observational studies and clinical trials have shown metabolic surgery to result in sustained weight loss (20-30%), T2D remission rates ranging from 23% to 60%, and improvement in cardiovascular risk factors such as hypertension and dyslipidemia. Metabolic surgery is cost-effective and relatively safe, with perioperative risks and mortality comparable to low-risk procedures such as cholecystectomy, hysterectomy, and appendectomy. International diabetes and medical organizations have endorsed metabolic surgery as a standard treatment for T2D with obesity.
The term metabolic surgery describes bariatric surgical procedures used primarily to treat type 2 diabetes and related metabolic conditions. Originally, bariatric surgery was used as an alternative weight-loss therapy for patients with severe obesity, but clinical data revealed its metabolic benefits in patients with type 2 diabetes. Metabolic surgery is more effective than lifestyle or medical management in achieving glycemic control, sustained weight loss, and reducing diabetes comorbidities. Perioperative adverse events are similar to other gastrointestinal surgeries. New guidelines for type 2 diabetes expand use of metabolic surgery to patients with a lower body mass index.
Long-term remission of type 2 diabetes following lifestyle intervention or pharmacotherapy, even in patients with mild disease, is rare. Long-term remission following metabolic surgery however, is common and occurs in 23% to 98% depending on disease severity and type of surgery. Remission after surgery is associated with excellent glycemic control without reliance on pharmacotherapy, improvements in quality of life, and major reductions in microvascular and macrovascular complications. For patients with type 2 diabetes, early intervention with metabolic surgery, when beta cell function still remains intact, provides the greatest probability of long-term remission as high as 90% or more.
A total of 36 patients with suspected foreign body (FB) of the oesophagus who underwent rigid endoscopy under general anaesthesia (GA) from January 2005 to March 2007 were reviewed. The majority of the patients were working adults in the 3rd to 5th decade of life. There was no foreign body in 33.3% of the patients. Co-morbidities were present in 33.3%. Morbidity and mortality from the procedure included one aspiration pneumonia, one lateral pharyngeal wall tear and one death (8.3%). X-ray findings were negative or inconclusive in 11(45.8%) patients with a foreign body. The majority of patients, 85.7% required 2 to 3 days of admission of which 52.7% had no foreign bodies. The most common foreign body retrieved was fishbone accounting for 13 of the 24 foreign bodies detected.
Patients who have had middle-ear or mastoid surgery are at an increased risk of developing cerebrospinal fluid (CSF) otorrhoea. The CSF leak is usually from defects in the tegmen or posterior cranial fossa. We present a patient with CSF otorrhoea following a modified radical mastoidectomy seven years ago. There was an unusual communication between the internal auditory meatus (IAM) and the middle ear. Radiologic imaging like the MRI is useful in identifying the site of leak.
A retrospective review of 100 walk-in patients at a specialized neurotology clinic in dizziness at a tertiary referral centre is presented. The most common cause of dizziness was BPPV, forming 31% of the cases. Other causes in order of frequency include recurrent vestibulopathy, idiopathic causes, Meniere's disease and central causes.
Study site: Neurotology clinic, Universiti Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Malignant melanocytic melanoma is a rare sinonasal malignancy. We present a case report of an elderly lady who presented with epistaxis and intranasal polyps. Computed tomography revealed soft tissue mass in the oropharynx, nasopharynx, left ethmoid and entire maxillary sinus. The mass was removed via endoscopic medial maxillectomy. Histopathology examination revealed sinonasal melanocytic malignant melanoma. At present 17 months postoperatively she is symptom free with no recurrence and under regular follow up.
We report a case of High grade Mucoepidermoid carcinoma of the middle ear. A 67 year old gentleman was referred to our centre for persistent otalgia associated with facial weakness for four months. Examination revealed a middle ear mass with House Brackmann Grade 3 Facial Palsy and ipsilateral lymhadenopathy. Biopsies suggested a squamous cell carcinoma of the middle ear, and he successfully underwent an Extended Temporal bone resection with External canal reconstruction and neck dissection. Postoperative Histopathology revealed that the tumour was in fact a High Grade Mucoepidermoid carcinoma. He received postoperative radiotherapy and is well one year post operatively.
This case report highlights an unusual case where a foreign body in the parotid gland was initially thought to be sialolithiasis based on CT scans. The foreign body was safely retrieved from the parotid gland without formal superficial parotidectomy using methylene blue and an image intensifier to localize the lesion. Diagnosis and management of foreign bodies in the parotid gland are reviewed, and surgical options in removal of such lesions are discussed.
The COVID-19 pandemic has led to a significant shift in the practice of almost all medical fields. Surgical specialities were particularly hard hit as these services had to give way to the more urgent management of COVID-19 patients both in-ward and in intensive care units. In otorhinolaryngology (ORL) practice, an additional issue to be dealt with was a relatively higher risk of being exposed to viral droplets from aerosol-generating procedures and examination of oral and nasal cavities of patients. This article describes our experience in managing ORL services at a government tertiary referral hospital, Hospital Raja Permaisuri Bainun, Ipoh, during the current COVID-19 outbreak since the year 2020. Two novel strategies were introduced namely the outsourcing of radiotherapy services for cancer patients and an innovative design in endoscopic examination of patients.
A Health Technology Assessment (HTA) was conducted in 2011 to evaluate whether transnasal oesophagoscopy (TNE) should be made available at otorhinolaryngology (ORL) clinics in the Ministry of Health facilities. The safety, efficacy or effectiveness and economic implication of using transnasal oesophagoscopy (TNE) were reviewed. This review provides a summary of the HTA and an updated literature review as well as how this technology might potentially affect services in the Ministry of Health.
Inverted papillomas (IPs) are benign sinonasal epithelial tumors that are locally aggressive and has a preponderance to recur if incompletely excised. This is a retrospective report describing 13 patients who underwent endoscopic excison from March 2004 to December 2010. Data was summarized into age, sex, location of tumor, surgical outcome and disease free status. Majority of the patients were males with the remaining 3 females, with a mean age of 50.9 years (range 24-76 years). Two patients needed an additional procedure of endoscopic dacrocystorhinostomy (EDCR) for epiphora. Out of the 13 patients surveyed, three patients underwent revision surgery for recurrences, of which one was a referred from another instituition. All patients are currently disease free. The mean follow-up period is 40 months.
Dacrycystorhinostomy (DCR) is a procedure performed to drain the lacrimal sac in cases of nasolacrimal duct obstruction or in chronic dacryocystitis. It can be performed externally or endoscopically. This is a prospective, nonrandomized study involving twenty-two consecutive patients (16 Females and 6 Males; mean age 45.54 y; range 18-74 y) who presented to the DCR clinic with epiphora secondary to nasolacrimal duct obstruction and recurrent infection. All patients underwent primary powered endoscopic DCR. A total of 24 procedures were performed using a standardized surgical technique. Post-operatively, symptom evaluation and endoscopic assessment of the newly created lacrimal ostium were done. Twenty-two of the 24 DCR's were patent after a mean follow-up of 21.5 months, yielding a success rate of 91.66%. Patency was assessed by symptomatic evaluation and endoscopic visualization at each post-operative visit. Two patients had complications, one orbital fat exposure and the other secondary haemmorhage. The two failures were due to synechiae formation. Therefore, powered endoscopic DCR with mucosal flaps without stenting has a success rate comparable to that achieved with stents and external DCR.
Fibrous dysplasia is a benign disease characterized by a progressive replacement of normal bone elements with fibrous tissue and the temporal bone involvement is uncommon. It has a male:female ratio of 2:1 and is seen more commonly in the first two decades of life. Diagnosis is made based on radiological findings and the modality of treatment is mainly conservative. However, surgery is reserved for preserving function and preventing complications. Fibrous dysplasia in the region of craniofacial bones is of particular interest to the otolaryngologist as it causes deformity and dysfunction that can be debilitating. We present a 49 year old Chinese gentleman with complaints of chronic dizziness over the last one year and had no obvious hearing impairment. Computed tomography of the mastoid revealed fibrous dysplasia of the right temporal bone. This case is of particular interest due to the late presentation as it is more commonly seen in the first two decades of life.
Eight patients with pituitary tumors were operated via the transseptal transsphenoidal approach from April to November 2004 at Hospital Ipoh. Seven patients presented with visual disturbances while three also had endocrine abnormalities. The post-operative follow-up period was between six months to a year. There was no mortality in this series. There were no complications related to the approach i.e. nasal or septal related. All patients with visual impairment showed improvement. Only one patient had hormonal irregularities. The endoscopic assisted transseptal approach to the sphenoid sinus for pituitary surgery was found to be easy and without sinonasal or labial complications often found with the sublabial approach.
Epistaxis is a common problem encountered in clinical practice. It is usually self-limiting and is usually controlled with conservative measures such as nasal compression or ice-packs. Occasionally nasal packing is required. It is rarely severe enough that surgical intervention is warranted. The following report illustrates a patient who presented to us with a rare cause of life-threatening epistaxis that is, a post-traumatic pseudoaneurysm who finally required surgical intervention to control the bleeding.