MyMedR

Velopharyngeal stenosis, a late complication of radiotherapy

Lee SC, Tang IP, Singh A, Kumar SS, Singh S

Auris Nasus Larynx, 2009 Dec;36(6):709-11.

PMID: 19304419 DOI: 10.1016/j.anl.2009.02.002

Choanal stenosis has recently been recognized as a late complication of radiation therapy for nasopharyngeal carcinoma. The management of velopharyngeal stenosis is challenging with high risk of restenosis. We report a case of velopharyngeal stenosis post-radiotherapy and illustrated the use of mitomycin-C to prevent restenosis. Mitomycin-C application has being shown useful adjunct to surgical technique in managing nasopharyngeal stenosis for surgeons.

Migrating foreign body into the common carotid artery and internal jugular vein--a rare case

Tang IP, Singh S, Shoba N, Rahmat O, Shivalingam S, Gopala KG, et al.

Auris Nasus Larynx, 2009 Jun;36(3):380-2.

PMID: 19019597 DOI: 10.1016/j.anl.2008.08.003

Ingested foreign bodies are a fairly common otorhinolaryngological emergencies encountered in Malaysia. The vast majority of these foreign bodies are fish bones which most commonly are impacted at the level of the cricopharynx. Rarely, however, a foreign body may migrate extraluminally and may even extrude subcutaneously. We report a rare occurrence where a fish bone not only migrated extraluminally, it was found to have migrated into the common carotid artery and the internal jugular vein and required surgical removal.

Fulltext Unilateral pulmonary vein atresia presenting with recurrent haemoptysis in a child: a case report

Wong MNL, Tang IP, Chor YK, Lau KS, John AR, Hii KC, et al.

BMC Pediatr, 2020 09 24;20(1):448.

PMID: 32972390 DOI: 10.1186/s12887-020-02348-7

BACKGROUND: Haemoptysis is an uncommon presenting symptom in children and is usually caused by acute lower respiratory tract infection or foreign body aspiration. We report a rare case of right unilateral pulmonary vein atresia (PVA) as the underlying aetiology of recurrent haemoptysis in a child.

CASE PRESENTATION: A 4 years old girl presented with history of recurrent haemoptysis. Bronchoscopic evaluation excluded a foreign body aspiration but revealed right bronchial mucosal hyperaemia and varices. Diagnosis of right unilateral PVA was suspected on transthoracic echocardiography which demonstrated hypoplastic right pulmonary artery and non-visualization of right pulmonary veins. Final diagnosis was confirmed on cardiac CT angiography. A conservative treatment approach was opted with consideration for pneumonectomy in future when she is older.

CONCLUSION: Rarer causes should be considered when investigating for recurrent haemoptysis in children. Bronchoscopy and cardiac imaging are useful tools to establish the diagnosis of unilateral PVA in our case.

Intrasellar pituitary mucocele: diagnostic dilemma

Tang IP, Chai CK, Kumar G, Prepageran N, Waran V

Br J Neurosurg, 2014 Jun;28(3):390-2.

PMID: 23875880 DOI: 10.3109/02688697.2013.817535

Isolated intrasellar pituitary mucocele following transsphenoidal sinus surgery is extremely rare. The clinical features resemble a pituitary tumor, therefore careful radiological interpretation is crucial to reach the correct diagnosis. We report a case of intrasellar mucocele who had transsphenoidal sinus surgery performed 15 years prior.

A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications

Waran V, Tang IP, Karuppiah R, Abd Kadir KA, Chandran H, Muthusamy KA, et al.

Br J Neurosurg, 2013 Dec;27(6):742-6.

PMID: 23647078 DOI: 10.3109/02688697.2013.791667

Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

Cavernous sinus fungal infection: a rare case

Ng BHK, Kho GS, Sim SK, Liew DNS, Tang IP

Br J Neurosurg, 2017 Jun 09.

PMID: 28597698 DOI: 10.1080/02688697.2017.1335857

Intracranial fungal infection of the cavernous sinus is a condition that usually affects immunocompromised individuals and is rarely seen in immunocompetent individuals. It is a potentially life threatening condition which requires prompt treatment. Here we present a case of an immunocompetent patient with a fungal infection of the cavernous sinus.

Fulltext A caroticocavernous fistula without vascular injury following endoscopic transsphenoidal excision of a tuberculum sellae meningioma-A case report

Ngui JZ, Higginbotham G, Kanesen D, Lau JH, Tang IP, Liew DNS

Clin Case Rep, 2021 May;9(5):e04117.

PMID: 34026157 DOI: 10.1002/ccr3.4117

Caroticocavernous fistulae can occur following transsphenoidal surgery even without evidence of carotid artery injury. A role of vascularized flap reconstruction may be contributory.

Evaluation and treatment of isolated sphenoid sinus diseases

Tang IP, Brand Y, Prepageran N

Curr Opin Otolaryngol Head Neck Surg, 2016 Feb;24(1):43-9.

PMID: 26575516 DOI: 10.1097/MOO.0000000000000218

To review cause, clinical evaluation, medical and surgical management of isolated sphenoid sinus diseases.

Management of sphenoid lateral recess encephalocoeles

Govindaraju R, Tang IP, Prepageran N

Curr Opin Otolaryngol Head Neck Surg, 2019 Feb;27(1):37-46.

PMID: 30507693 DOI: 10.1097/MOO.0000000000000508

PURPOSE OF REVIEW: Sphenoid sinus lateral recess encephalocoeles (SSLRE) are rare occurrences and pose unique challenges due to limited surgical access for endoscopic endonasal repair and also the lack of consensus on optimal perioperative managements specifically in the spontaneous cases, which are also believed to be a variant of idiopathic intracranial hypertension (IIH). Endoscopic endonasal approaches have largely replaced the transcranial route and the techniques are continuously being refined to reduce the neurovascular morbidity and improve outcome.

RECENT FINDINGS: Transpetrygoid is the most utilized approach with modifications suggested to limit bone removal, exposure and preservation of the neurovascular structures as dictated by the extent of the lateral recess. As more experience is gained, extended transphenoidal techniques were also successfully used for access. Lateral transorbital is a new approach to the lateral recess investigated in cadavers. IIH treatment is still controversial in the setting of SSLRE, but it appears rationale to evaluate, monitor and treat if necessary.

SUMMARY: SSLRE management should be tailored to the specific anatomical variances and cause. Modifications of techniques have been described giving different options to access the lateral recess. Successful repair for spontaneous SSLRE may require treatment of IIH if present, but the long-term outcome is still unclear.

Bilateral nontuberculous mycobacterial middle ear infection: a rare case

Tang IP, Singh S, Rajagopalan R

Ear Nose Throat J, 2014 Sep;93(9):390-4.

PMID: 25255345

Nontuberculous Mycobacterium (NTM) middle ear infection is a rare cause of chronic bilateral intermittent otorrhea. We report a rare case of bilateral NTM middle ear infection in which a 55-year-old woman presented with intermittent otorrhea of 40 years' duration. The patient was treated medically with success. We conclude that NTM is a rare but probably under-recognized cause of chronic otitis media. A high index of suspicion is needed for the diagnosis to avoid prolonged morbidity. Treatment includes surgical clearance of infected tissue with appropriate antimycobacterial drugs, which are selected based on culture and sensitivity.

Cervical lipoblastoma: An uncommon presentation

Jaafar R, Tang IP, Jong DE, Narihan MZ

Ear Nose Throat J, 2015 Jul;94(7):E8-10.

PMID: 26214680

Lipoblastoma is extremely rare and mainly occurs in children younger than 3 years old. It is predominantly found in the extremities and trunk. Head and neck region occurrences are rare; only 4 such cases involving patients who presented with stridor have been previously reported. We report the fifth case of lipoblastoma of the neck with stridor in a 9-year-old girl, which had gradually worsened over the previous year. Imaging showed a retrotracheal mass extending superiorly to the thyroid level and inferiorly to below the carina of the trachea. Total resection of the tumor was performed, and the histopathologic findings were consistent with lipoblastoma. Postoperatively, the patient was well with no complications.

3 Tesla magnetic resonance imaging noise in standard head and neck sequence does not cause temporary threshold shift in high frequency

Lim EY, Tang IP, Peyman M, Ramli N, Narayanan P, Rajagopalan R

Eur Arch Otorhinolaryngol, 2015 Nov;272(11):3109-13.

PMID: 25205300 DOI: 10.1007/s00405-014-3232-y

High acoustic noise level is one of the unavoidable side effects of 3 T magnetic resonance imaging (MRI). A case of hearing loss after 3 T MRI has been reported in this institution and hence this study. The objective of this study was to determine whether temporary threshold shift (TTS) in high frequency hearing occurs in patients undergoing 3 T MRI scans of the head and neck. A total of 35 patients undergoing head and neck 3 T MRI for various clinical indications were tested with pure tone audiometry in different frequencies including high frequencies, before and after the MRI scan. Any threshold change from the recorded baseline of 10 dB was considered significant. All patients were fitted with foamed 3 M earplugs before the procedure following the safety guidelines for 3 T MRI. The mean time for MRI procedure was 1,672 s (range 1,040-2,810). The noise dose received by each patient amounted to an average of 3,906.29% (1,415-9,170%). The noise dose was derived from a normograph used by Occupational Noise Surveys. This was calculated using the nomograph of L eq, L EX, noise dose and time. There was no statistically significant difference between the hearing threshold before and after the MRI procedures for all the frequencies (paired t test, P > 0.05). For patients using 3 M foamed earplugs, noise level generated by 3 T MRI during routine clinical sequence did not cause any TTS in high frequency hearing.

A 4-year review of surgical and oncological outcomes of endoscopic endonasal transpterygoid nasopharyngectomy in salvaging locally recurrent nasopharyngeal carcinoma

Tang IP, Ngui LX, Ramachandran K, Lim LY, Voon PJ, Yu KL, et al.

Eur Arch Otorhinolaryngol, 2019 Sep;276(9):2475-2482.

PMID: 31227870 DOI: 10.1007/s00405-019-05522-5

PURPOSE: To study the surgical and oncological outcomes of endoscopic endonasal transpterygoid nasopharyngectomy (EETN) in salvaging locally recurrent nasopharyngeal carcinoma (NPC).

METHOD: This was a retrospective clinical record review study carried out at a tertiary centre from June 2013 until May 2017. A total of 55 locally recurrent NPC patients (rT1-rT4) underwent EETN performed by single skull base surgeon with curative intention with postoperative adjuvant chemotherapy but without postoperative radiotherapy.

RESULTS: There were 44 (80.0%) males and 11 (20.0%) females, with mean age of 52.5 years. The mean operating time was 180 min (range 150-280 min). 85% (47/55) of patients achieved en bloc tumour resection. 93% (51/55) of patients obtained negative microscopic margin based on postoperative histopathological evaluation. Intraoperatively, one (1.8%) patient had internal carotid artery injury which was successfully stented and had recovered fully without neurological deficit. There were no major postoperative complications reported. During a mean follow-up period of 18-month (range 12-48 months) postsurgery, five patients (9.1%) had residual or recurrence at the primary site. All five patients underwent re-surgery. One patient at rT3 passed away 6 months after re-surgery due to distant metastasis complicated with septicaemia. The 1-year local disease-free rate was 93% and the 1-year overall survival rate was 98%.

CONCLUSIONS: EETN is emerging treatment options for locally recurrent NPC, with relatively low morbidity and encouraging short-term outcome. Long-term outcome is yet to be determined with longer follow-up and bigger cohort study. However, a successful surgical outcome required a very experienced team and highly specialised equipment.

A recurrent nasopharyngeal carcinoma with lacrimal sac involvement: a case report

Tang IP, Periyannan P, Prepageran N, Shashinder S, Singh A, Bhagubhai PN

Eur J Cancer Care (Engl), 2011 Jan;20(1):93-5.

PMID: 20088917 DOI: 10.1111/j.1365-2354.2009.01147.x

We report a very rare case of recurrent nasopharyngeal carcinoma with local involvement of lacrimal sac. The patient was treated with chemotherapy and there was no recurrence noted after 1 year of follow-up.

Fulltext Adenoid Cystic Carcinoma of the Nasopharynx: A Case Series

Ng BHK, Tang IP

Indian J Otolaryngol Head Neck Surg, 2019 Oct;71(Suppl 1):731-733.

PMID: 31742052 DOI: 10.1007/s12070-018-1523-0

Adenoid cystic carcinomas are tumors that are more commonly seen in the salivary glands than in the nasopharynx. Nasopharyngeal adenoid cystic carcinomas are rare and cases that are reported in the literatures are few. Treatment is mainly by surgical resection. Here, we report 2 cases of nasopharyngeal adenoid cystic carcinoma.

Fulltext Laryngeal Leiomyosarcoma: A Rare Case

Ng BHK, Tang IP, Suhashini G, Chai CK

Indian J Otolaryngol Head Neck Surg, 2019 Oct;71(Suppl 1):795-797.

PMID: 31742066 DOI: 10.1007/s12070-018-1553-7

Laryngeal leiomyosarcoma is a rare smooth muscle malignancy of the head and neck region. Diagnosis is based on immunohistochemistry. Here we present a case of laryngeal leiomyosarcoma that was diagnosed and treated in our center, focusing on the clinical features, histological diagnosis and management of this rare disease.

Fulltext Radiological Study of the Ethmoidal Arteries in the Nasal Cavity and Its Pertinence to the Endoscopic Surgeon

Kho JPY, Tang IP, Tan KS, Koa AJ, Prepageran N, Rajagopalan R

Indian J Otolaryngol Head Neck Surg, 2019 Nov;71(Suppl 3):1994-1999.

PMID: 31763282 DOI: 10.1007/s12070-018-1415-3

We studied the ethmoidal arteries using preexisting computer tomography of the paranasal sinuses (CT PNS) and statistically scrutinized data obtained between genders. A descriptive study from 77 CT PNS dated January 2016-December 2016 were collected and reviewed by two radiologists. A total of 54 (108 sides) CT PNS were studied of patients aged 18-77 years. 37 are male, 17 are female; with Bumiputera Sarawak predominance of 25 patients, 12 Malays, 16 Chinese and one Indian. Rate of identification are as follows: anterior ethmoidal artery (AEA)-100%, middle ethmoidal artery (MEA)-30%, posterior ethmoidal artery (PEA)-86%. The average distance from AEA-MEA is 8.1 ± 1.52 mm, MEA-PEA is 5.5 ± 1.29 mm and AEA-PEA is 12.9 ± 1.27 mm. The mean distance from PEA-the anterior wall of sphenoid is 7.7 ± 3.96 mm, and PEA-optic canal is 8.5 ± 3.1 mm with no statistical difference when compared between gender. AEA frequently presented with a long mesentery 57.4%, while 87.1% of PEA was hidden in a bony canal. The vertical distance of the AEA-skull base ranges from 0 to 12.5 mm whilst PEA-skull base is 0-4.7 mm. There is no statistical difference in distances of AEA, MEA nor PEA to skull base when analyzed between genders; t(82) = 1.663, p > 0.05, t(32) = 0.403, p > 0.05 and t(75) = 1.333, p > 0.05 respectively. We newly discovered, that 50% of MEA is hidden in a bony canal, and its distance to skull base ranged 0-5.3 mm. MEA and PEA less commonly have a short or long mesentery. Knowledge on the ethmoidal arteries especially in our unstudied population of diverse ethnicity, gains to assist surgeons worldwide, when embarking in endoscopic transnasal surgeries.

Endoscopic Endonasal Approach in Clival Chordoma Surgery: Case Series

Ngu CYV, Tang IP, Ng BHK, Wong ASIIH, Liew DNS

Indian J Otolaryngol Head Neck Surg, 2021 Jun;73(2):226-232.

PMID: 34150596 DOI: 10.1007/s12070-021-02455-6

Chordomas are rare and slow-growing locally destructive bone tumors that can develop in the craniospinal axis. It is commonly found in the sacrococcygeal region whereas only 25-35% are found in the clival region. Headache with neurological deficits are the most common clinical presentations. Complete surgical resection either via open or endoscopic endonasal approaches are the main mode of treatment. Here, we report a series of 5 cases of clival chordomas which was managed via endoscopic endonasal approaches in our center. A retrospective analysis of patients who had undergone endoscopic endonasal resection of clival chordoma in Sarawak General Hospital from 2014 to 2018. A total of 5 cases were operated on endoscopically via a combine effort of both the otorhinolaryngology team and the neurosurgical team during the study period from year 2013 to 2018. From our patient, 2 were female and 3 were male patients. The main clinical presentation was headache, squinting of eye and nasopharyngeal fullness. All our patient had endoscopic endonasal debulking of clival tumor done, with average of hospital stay from 9 - 23 days. Pos-operatively, patients were discharged back well. Endoscopic endonasal resection of clival chordomas gives good surgical resection results with low morbidity rates and therefore can be considered as a surgical option in centers where the surgical specialties are available.

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

Goh SP, Wilfred R, Husain S, Tang IP

Indian J Otolaryngol Head Neck Surg, 2023 Apr;75(Suppl 1):1096-1100.

PMID: 37206815 DOI: 10.1007/s12070-023-03625-4

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.

Fulltext A Rare Case of Cerebrospinal Fluid Rhinorrhea from Canal of Stenberg

Ngu CYV, Lee TH, Ramachandran K, Liew DNS, Tang IP

Indian J Otolaryngol Head Neck Surg, 2023 Apr;75(Suppl 1):764-767.

PMID: 37206705 DOI: 10.1007/s12070-022-03347-z

Background: A spontaneous cerebrospinal leak from Sternberg's canal with meningoencephalocele is a very rare clinical entity. Endoscopic repair of the defect is challenging and crucial in identifying the defect. The aim of this case report is to highlight the presence and management with endoscopic surgery in repairing Sternberg canal. Case: 40-year-old woman presents with spontaneous CSF rhinorrhea with no predisposing factors. CT imaging and MRI showed osteodural defect in the lateral recess of sphenoid with meningoencephalocoele lateral to the foramen rotundum. Endoscopic transethmoidal - transphenoidal - transpterygoid approach was used to repair the defect, and patient is well post-operative with least complication from the intervention surgery. Conclusion: Endoscopic approach proved to be the best and safest method in localizing the defect and closure of the leak. Angled scopes and image guided system were used to identify the precise location of the leak.

SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12070-022-03347-z.

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