In this case series, the senior author details his series of patients who had undergone open septorhinoplasty for functional and/or aesthetic purposes in the Otorhinolaryngology Department at the Hospital Universiti Kebangsaan Malaysia (HUKM), Kuala Lumpur between January 2003 and September 2005. There were 23 patients, consisting of 15 men and 8 women from different Malaysian ethnic groups. Discussion on open septorhinoplasty with regards to operative technique, grafts and implants is presented from an otorhinolaryngologist's point of view.
A retrospective review was performed on 11 patients who had undergone the transcolumellar transsphenoidal hypophysectomy in our center. There were eight females and three males with age ranging from 17 to 72 years (mean 50 years). Ten patients had pituitary macroadenomas and one had suprasellar cyst. The mean follow up duration for these 11 patients post surgery was 7.2 months. Complications included two cerebrospinal leaks, one postoperative sphenopalatine bleed, one septal perforation and one patient developed numbness of the tip of the nose. We found that this approach is a preferred alternative technique especially in smaller Oriental noses with lower complication rate and better aesthetic result.
Surgery for pituitary tumours at our institution was performed by rhinosurgical route by combined procedure by otolaryngologist and neurosurgeons. A retrospective review of case records of patients who had endonasal endoscopic transphenoidal approach for pituitary tumours from September 1998 to December 2004 was performed. A total of 81 trans-sphenoidal surgeries were performed during this study period. Only 68 case records with adequate information were available for review, 56 patients were included in the study and 12 were excluded. There were 24 males (42%) and 32 females (58%). The ethnic distribution, were 29 Malays, 24 Chinese, 2 Indian and 1 others. The age ranged from 16 years to 76 years, with a mean of 46 years. The majority of our patients presented with visual symptoms (38), headache (28), menstrual cycle disturbance or impotence (14) and acromegalic features (16). Forty patients had macroadenoma (71%) and 16 had microadenomas (29%). Thirty-six patients out of 40 macro-adenomas had suprasellar extensions (90%). Only eleven patients had lumbar drain inserted prior to commencement of the surgery and the majority of these were macroadenomas. The common complications encountered were diabetes insipidus (4), cerebrospinal fluid leak (2), meningitis (3), epistaxis (2), septal perforation (2), intercavernous sinus haemorrhage (3) and anterior pituitary insufficiency (2). Our study reveals that endonasal trans-sphenoidal approach is a safe and effective method of management of pituitary adenomas.
The purpose of this retrospective study is to determine the pattern of cerebrospinal fluid (CSF) rhinorrhoea presenting to our tertiary referral centre in Kuala Lumpur and to assess the clinical outcomes of endonasal endoscopic surgery for repair of anterior skull base fistulas. Sixteen patients were treated between 1998 and 2004. The aetiology of the condition was spontaneous in seven and acquired in nine patients. In the acquired category, three patients had accidental trauma and this was iatrogenic in six patients (five post pituitary surgery), with one post endoscopic sinus surgery (ESS). Imaging included computed tomography (CT) scan and magnetic resonance imaging (MRI). Endoscopic repair is less suited for defects in the frontal sinuses with prominent lateral extension and defects greater than 1.5 cm in diameter involving the skull base. Fascia lata, middle turbinate mucosa, nasal perichondrium and ear fat ('bath plug') were the preferred repair materials in the anterior skull base, whereas fascia lata, cartilage and abdominal fat obliteration was preferentially used in the sphenoid leak repair. Intrathecal sodium flourescein helped to confirm the site of CSF fistula in 81.3 per cent of the patients. Ninety per cent of the patients who underwent 'bath plug' repair were successful. The overall success rate for a primary endoscopic procedure was 87.5 per cent, although in two cases a second endoscopic procedure was required for closure. In the majority of cases endoscopic repair was successful, and this avoids many of the complications associated with craniotomy, particularly in a young population. Therefore it is our preferred option, but an alternative procedure should be utilized should this prove necessary.
Atopy is defined as the genetic propensity to develop immunoglobulin E antibodies in response to exposure to allergens and assessed by skin prick test (SPT) responses to common allergens, which may contribute to the development of the clinical disorders (phenotype). Although it is generally agreed that atopy is an important risk factor for allergic diseases such as asthma, rhinitis, and eczema, the extent to which atopy accounts for these diseases is controversial. One hundred forty one children (up to 12 years) were skin prick tested to evaluate 16 foods common to the Malaysian diet and 4 common aeroallergens. Eighty-five percent of patients had positive SPT reactivity. The most commonly implicated aeroallergen and food allergen was house dust mite (HDM) and Prawn. Seventy percent had positive SPT reactivity results to HDM and 24.8% to prawns. Fifty five percent were positive to more than one allergen and 17.7% positive to single aeroallergen. The prevalence of atopy in children with history of eczema was 90%. The incidence of HDM and food allergy especially crabs and prawns, is significantly greater in Malaysian Children with rhinitis symptoms.
Septal perforation from intranasal cocaine abuse is well recognised. We present a case of progressive septal as well as palatal perforation. Progression from septal perforation to palatal perforation occurred after cessation of intranasal cocaine abuse. This patient had a weakly positive cytoplasmic antineutrophilic cytoplasmic antibody (C-ANCA) but no histologic evidence of Wegener's Granulomatosis. The differential diagnosis for septal and palatal perforation is reviewed. This case represents the fifth reported case of palatal perforation secondary to cocaine abuse in the literature, and the second associated with positive C-ANCA.
The strong international demand for admission into medical schools make medical education a "seller's market", and increasingly a global market. Teaching of Otorhinolaryngology-Head and Neck Surgery (ORL-HNS) has two primary goals. Firstly, a firm grasp of basic principles, recognition and treatment of common disorders, initial management of ORL-HNS emergencies and indications for specialist referral. Secondly, to provide sufficient exposure to the specialty to assist in career planning. Good communicative skills for optimal patient care are essential in the selection criteria of medical students. Proficiency in English is essential to obtain a disproportion share of opportunities in the new economy. The examination evaluation needs to be standardized between the various medical schools and the recommended lecturer-student ratio is maintained. The Joint National Evaluating Board has a very essential role to play in the maintenance of medical educational standards in Malaysia.
Although some form of commercial instrument mounting arm is available, a paucity of information in the literature may cause problems in selecting the most appropriate model for an ENT department wishing to trial their invention for use in the clinic or operating theatre. The instrument mounting arm described here is based on existing designs used by hobbyists and model makers for many years but the main benefit of this innovation is its multi-purpose use in the operating theatre and cost effectiveness since it is made of aluminum alloy. It is compact, stable and easily adjustable and can incorporate an endoscope holder or an operating end piece to mount various ENT instruments that offers considerable advantages to the unassisted operator.
Different modalities of turbinate reduction procedures are available for treatment of vasomotor rhinitis not responding to appropriate medical therapy. Amongst these, conventional inferior turbinectomy (non-endoscopic) is the most widely performed procedure. With the advent of nasal endoscopes, inferior turbinoplasty has been gaining popularity worldwide. The purpose of this study was to compare the post-operative complaints and hospital stay of conventional versus endoscopic inferior turbinate reduction techniques performed non-randomly on 15 and 21 patients of vasomotor rhinitis respectively from January 1998 to December 1999 at Hospital Universiti Kebangsaan Malaysia (HUKM). A total of 36 patients (22 males and 14 females) with a mean age of 30.6 years underwent turbinate reduction procedures during this period with a post-operative follow up ranging from 3 months to 6.7 months (mean 3.8 months). There was a significant difference between the conventional and the endoscopic technique with regards to nasal discomfort (p = 0.05) and dry throat (p = 0.02) which was less severe when performed endoscopically. The average hospital stay in hours by the endoscopic technique was almost half compared to the conventional technique. Due to the improved visualisation and minimal post-operative complaints and reduced hospital stay, the technique of endoscopic inferior turbinoplasty is currently the procedure of choice at our center. In septoplasty when endoscopic instrument is not needed, the standard turbinate reduction procedure is still performed. The availability of pre and post-operative acoustic rhinomanometric evaluation will be helpful as an objective measurement of nasal symptoms in the near future.
Three cases of spontaneous Cerebrospinal Fluid (CSF) rhinorrhea were managed at the National University Hospital, Kuala Lumpur. Case 1 had bilateral leak secondary to empty sella syndrome and the rest two cases had unilateral leak. Four transnasal endoscopic approaches were performed on these three cases since March 1999. The role of intrathecal Sodium Fluorescein is highlighted in localising the CSF fistula. Case 3 required postoperative lumbar drain as an adjunct. No recurrent leak was noted on post operative follow up in Case 2 and 3 ranging from nine to thirty two months. A recurrent left leak at six months was noted in Case 1 which could likely be due to her sudden bout of cough attacks and patient refused further surgical intervention.
The aim of the study was to determine the incidence of food and house dust mite (HDM) allergy in patients with nasal congestion and rhinorrhea attending the Otorhinolaryngology Clinic, National University of Malaysia, Kuala Lumpur. This was a prospective matched, controlled study of patients skin prick tested with commercial food and common aeroallergens. The participants were 148 Malaysian adults with symptoms of nasal congestion and rhinorrhea and 113 adult Malaysian control subjects without rhinitis symptoms. The skin prick test (SPT) was used to evaluate 11 foods common to the Malaysian diet and 3 HDM inhalants. Forty-eight percent of the patients with rhinitis had positive SPT results to foods, compared with 4.4% of control subjects (P < 0.05). The most commonly implicated foods were shrimp (48%) and rice (30%), which are common in the Malaysian diet. Seventy-two percent of rhinitis patients had positive SPT results to HDM, compared with 22.2% of control subjects (P < 0.05). Patients with rhinitis also had significantly more gastrointestinal problems than control subjects (P < 0.05). The incidences of HDM and food allergy are significantly greater in Malaysian adults with rhinitis symptoms than in control subjects without rhinitis. The effect of avoidance or immunotherapy awaits further study.
Study site: Otorhinolaryngology Clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
A prospective study was undertaken in 16 patients with chronic renal failure on continuous ambulatory peritoneal dialysis, with 22 episodes of peritonitis treated with vancomycin, a known ototoxic agent. Twelve patients had one episode each, and four had recurrent peritonitis. Each treatment course consisted of two infusions of vancomycin (30 mg/kg body weight) in 2 L of peritoneal dialysate administered at 6-day intervals. Serum vancomycin analyzed by enzyme immunoassay showed a mean trough level of 11.00 microg/ml on day 6 and mean serum levels of 33.8 and 38.6 microg/ml about 12 hours after administration on days 1 and 7, respectively. Similar levels, well within the therapeutic range, were encountered with repeated vancomycin therapy for recurrent episodes of peritonitis, suggesting that no changes occurred in the pharmacokinetic profile of the drug. Pure-tone audiometry, electronystagmography, and clinical assessment performed during each course of treatment showed no evidence of ototoxicity even on repeated courses of vancomycin therapy. The results suggest that vancomycin therapy when given in appropriate concentrations as a single therapeutic agent is both effective and safe. We believe, however, that vancomycin administered in combination with an aminoglycoside may produce ototoxic effects that may be greatly aggravated, possibly because of synergism.
Internal jugular vein ectasia is a venous anomaly commonly presenting as a unilateral neck swelling in children and adults. Literature reports of bilateral presentation are rare. Bilateral Doppler ultrasonography is the diagnostic investigation of choice. The possible pathology, aetiology and management are discussed. Conservative management of bilateral cases is recommended in uncomplicated cases.
Although some form of temporal bone holder is in use in virtually all ENT postgraduate teaching departments, a paucity of information in the literature may cause problems in selecting the most appropriate model to those responsible for equipping temporal bone laboratories. The bone holder which we describe is based on existing designs but incorporates a built-in irrigation system which offers considerable advantages to the unassisted operator.
A prospective study was undertaken of 10 chronic renal failure patients on Continuous Ambulatory Peritoneal Dialysis (CAPD) complicated by repeated bouts of peritonitis treated with gentamicin. Each 10-day treatment course consisted of a 120 mg loading dose, followed by 16 mg in 21 of peritoneal dialysate, given four times a day. Serum gentamicin analysed by enzyme immunoassay showed a mean level of 5.2 micrograms/ml, (range 3.7 to 6.6 mg/ml) four hours after the loading dose. Similar levels, well within the therapeutic range, were maintained on the 3rd, 5th, 7th and 9th days of intraperitoneal gentamicin therapy, suggesting no accumulation of gentamicin in the serum. Pure tone audiometry, electronystagmography and clinical assessment were performed during each course of treatment. Although no evidence of ototoxicity was found during the first two courses of gentamicin, but disequilibrium and bobbing oscillopsia were present during the third and fourth courses of gentamicin. These findings could be explained by cumulative injury to the vestibular apparatus caused by repeated therapeutic insults.
In a prospective study on 47 patients, 16 mg of gentamicin per two litres dialysate was administered intraperitoneally at every cycle of intermittent peritoneal dialysis, carried out over the course of several days. Serum gentamicin sampling, pure tone audiometry and caloric tests were performed before and during the treatment. The gentamicin levels reached at the end of the thirtieth cycle were observed to be low. In view of this, the risk of acute ototoxicity was considered to be minimal. This was confirmed by the absence of clinical audiometric or vestibulometric evidence of toxicity.
Antrochoanal polyps are a rare clinical entity. In this review of patients treated between January 1996 and September 2002, there were 18 cases of antrochoanal polyps. The mean age of patients was 20 years. Nasal obstruction was the most common symptom (17 cases, 94%), followed by rhinorrhoea (44%), epistaxis (33%), postnasal drip (28%), and snoring (22%). Chronic sinus was the most common associated rhinological finding (50%). Various surgical approaches were used: endoscopic polypectomy and middle meatal antrostomy in seven patients (38.9%), endoscopic polypectomy and inferior meatal antrostomy in three patients (16.7%) and Caldwell-Luc surgery in one patient (5.6%). No complications were noted in patients treated with powered instrumentation, including the three patients in whom combined transcanine approaches were used. We concluded that powered endoscopic polypectomy was safe and effective. It allowed a more complete dissection and may diminish the chance of recurrence.
Foreign body aspiration in children is a problem that can lead to several complications, including death. In this retrospective publication review from 1970 to 2015, there were altogether 42 Malaysian children below the age of 15 y reported with foreign body (FB) ingestion. There were 31 boys and 11 girls between 2 and 177 mo of age. The incidence of FB ingestion in children varied with dietary practices. Peanut was the most common food-related substance inhaled followed by watermelon seed and coconut kernel. The most common non-food related substances were metal objects (toys, springs, hair clips) and plastic objects (ballpoint tips, pencil caps and whistles). Successful removal of FB by bronchoscopy is achieved in the vast majority of cases except for a case of impacted whistle inhalation and a neglected laryngeal FB which required a tracheostomy. One child required thoracotomy for the removal of a peanut in the right bronchus. The incidence of food-related substance inhalation was more common than non-food related substance (30:7). From this review, the key messages are two: first, prevention can be achieved by educating parents not to allow access to small objects or dangerous foods to children below 3 y age; Second, emergency first aid home measures, in the combination form of back blows in the head down position and chest or abdominal thrusts, should be early performed according to the pediatric age group and can be quite effective.
Sinus surgery has the potential of allowing ENT surgeons to encroach the boundaries of our colleagues in ophthalmology and neurosurgery. The advent of nasal endoscope and lately powered instrumentation and computer-assisted navigational systems has avoided the use of the conventional and more radical approaches by the ENT surgeon for the treatment of inflammatory pathology or tumors of the orbit and skull base. As rhinologists have gained more experience in endoscopic surgery, more areas related to the orbit and the anterior skull base are accessible and surgery is safer.