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A unilateral mesenchymal disorder of the head

Raman R, Kumar V, Arianayagam S, Peh SC

J Craniomaxillofac Surg, 1989 Apr;17(3):143-5.
PMID: 2708537

A hitherto undescribed group of lesions consisting of cystic bony lesions, exostosis, fibromatous lesion, unilateral tonsillar hypertrophy, epidermoid cyst (cholesteatoma) and hyperplasia of the mandible confined to the left side of the face is reported. The case may represent a variant of the Proteus syndrome.
Fulltext The Role of Occlusion of the External Ear Canal in Hearing Loss

Narayanan DA, Raman R, Chong AW

Turk Arch Otorhinolaryngol, 2019 Sep;57(3):122-126.
PMID: 31620693 DOI: 10.5152/tao.2019.3875

Objective: The objectives are to determine and compare the degrees of hearing loss upon occlusion of the cartilaginous and the bony portion of the external ear canal (EAC).
Methods: There were 20 healthy participants with normal ears, and all gave an informed consent. After an otoscopy, a baseline pure tone audiogram (PTA) was conducted. If the PTA of the participant was normal, aqueous cream was applied with a syringe via an 18 G cannula, from the tympanic membrane up to the isthmus which corresponds to the bony ear canal. A second PTA was conducted, and subsequently the cream was removed via suction under microscope guidance. The procedure was then repeated with the cream applied from the isthmus to the aperture of the external ear canal using the same cannula followed by a PTA and removal of cream under microscope.
Results: The mean threshold difference of occlusion at both portions of the ear canal were compared and analyzed. The mean threshold difference of hearing loss upon occlusion at the cartilaginous EAC was 37.5 to 48 dB. The mean threshold difference of hearing loss upon occlusion at the bony EAC was less, with a range of 21 to 24.95dB. There was a statistical difference (p<0.05) in the hearing loss between the blockage of the cartilaginous canal versus the blockage of the bony canal with a maximum difference at 2kHz.
Conclusion: Cartilaginous block of the external ear canal causes more hearing loss than block of the bony ear canal. This correlates with the concept and properties of sound waves, resonance and impedance.
Fulltext The role of sensation in subjective and objective evaluation of nasal patency

Dipak S, Prepageran N, Haslinda S, Atiya A, Raman R

Indian J Otolaryngol Head Neck Surg, 2011 Jan;63(1):10-4.
PMID: 22319710 DOI: 10.1007/s12070-010-0067-8

To assess if sensation of nasal mucosa affect the subjective sensation of nasal patency. This is a case control study with 50 patients, using 2% lignocaine as the active drug and normal saline as the placebo (2 groups of 25 patients each). Each subject had 2 ml of solution sprayed into the test nose. These subjects had no prior nasal symptoms, allergy or surgery. They were evaluated subjectively using Likert scale and objectively by acoustic rhinometry before and after lignocaine or normal saline. The patients in both normal saline and lignocaine groups demonstrated no significant change based upon Likert scale. The study also demonstrated the mean cross sectional area 1 (CSA1), mean cross sectional area 2 (CSA2), with mean Volume 1 and mean Volume 2, these results did not vary significantly in both groups with Acoustic Rhinometry. The analysis thus shows that the use of topical anesthetic spray on nasal mucosa produces no objective effect on nasal resistance or subjective sensation of altered nasal patency. Thus the study concludes that, tactile sensation of nasal mucosa does not play a role in the sensation of nasal obstruction.
Study of epithelial migration in the tympanic membrane and bony external auditory canal wall in patients with irradiated nasopharyngeal carcinoma

Santhi K, Prepageran N, Tang IP, Raman R

Otol Neurotol, 2015 Feb;36(2):318-22.
PMID: 24751743 DOI: 10.1097/MAO.0000000000000378

The objectives of this study were to determine the presence of epithelial migration in patients with postirradiated nasopharyngeal carcinoma (NPC) and to compare the rate of epithelial migration in the tympanic membrane (TM) and the bony external auditory canal (EAC) of postirradiated NPC ears with normal ears by means of the ink dot method.
The effectiveness of transmeatal low-power laser stimulation in treating tinnitus

Ngao CF, Tan TS, Narayanan P, Raman R

Eur Arch Otorhinolaryngol, 2014 May;271(5):975-80.
PMID: 23605244 DOI: 10.1007/s00405-013-2491-3

The aim of this study is to examine the effectiveness of transmeatal low-power laser stimulation (TLLS) in treating tinnitus. This is a prospective, double-blinded, randomized, placebo-controlled trial. Patients with persistent subjective tinnitus as their main symptom were recruited into the study from the outpatient clinics. The recruited patients were randomized into the experimental group or TLLS+ group (patients in this group were prescribed to use TLLS at 5 mW at 650 nM wavelength for 20 min daily and oral betahistine 24 mg twice per day for a total of 10 weeks) and the control group or TLLS- group (patients in this group were prescribed with a placebo device to use and oral betahistine 24 mg twice per day for 10 weeks). All patients were required to answer two sets of questionnaires: the Tinnitus handicap inventory (THI) and visual analogue scales (VAS) symptoms rating scales, before starting the treatment and at the end of the 10-week treatment period. The total score of the THI questionnaire was further graded into five grades, grade 1 being mild and grade 5 being catastrophic. Wilcoxon-signed ranks test and Mann-Whitney test were used to compare and analyze the THI and VAS scores before and after treatment for each group. Changes with p value of <0.05 were considered as statistically significant. Chi square test was used to analyze the change of parameters in categorical forms (to compare between TLLS+ and TLLS-). Changes with p value of <0.05 were considered as statistically significant. Forty-three patients successfully and diligently completed their treatment. It was noted that using any condition of the device, TLLS+ or TLLS-, patient's tinnitus symptoms improved in terms of THI scores (TLLS+, p value = 0.038; TLLS-, p value = 0.001) or VAS scores with a change of at least one grade (TLLS+, p value = 0.007; TLLS-, p value = 0.002) at p value <0.05 significant level. In contrast when TLLS+ group was compared with TLLS- group, no statistically significant result was obtained. In term of VAS scores, there seems to be no statistically significant improvement in patients' annoyance, sleep disruption, depression, concentration and tinnitus loudness and pitch heard between the two groups. Transmeatal low-power laser stimulation did not demonstrate significant efficacy as a therapeutic measure in treating tinnitus.
Study site: Otorhinolaryngology clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Iatrogenic tracheal flap mimicking tracheal stenosis with resultant stridor

Tan KL, Chong AW, Amin MA, Raman R

J Laryngol Otol, 2012 Jul;126(7):751-5.
PMID: 22578299 DOI: 10.1017/S0022215112000795

To illustrate a case of an iatrogenic mucosal tear in the trachea which caused a one-way valve effect, obstructing the airway and manifesting as post-extubation stridor.
Epithelial migration on the external ear canal wall in normal and pathologic ears

Revadi G, Prepageran N, Raman R, Sharizal TA

Otol Neurotol, 2011 Apr;32(3):504-7.
PMID: 21307812 DOI: 10.1097/MAO.0b013e31820d97e2

HYPOTHESIS: Epithelial migration on the external auditory canal (EAC) wall is abnormal in ears with keratosis obturans (KO).
BACKGROUND: Earlier studies of epithelial migration have focused on the tympanic membrane with scattered information available for epithelial migration on canal walls. This study was undertaken to observe the epithelial migration on the EAC wall in normal ears and in ears with KO.
METHODS: Twenty-five subjects with normal ears and 4 with KO were recruited for the study. Colored ink dots were placed around the tympanic annulus at the 12, 3, 6, and 9 o'clock positions. Migration patterns and the rate of travel of these ink dots were examined and photographed until the ink dots reached the bony cartilaginous junction.
RESULTS: Fifteen healthy subjects and 1 with bilateral KO completed the study. The ink dots migrated laterally, with a rate of migration in normal ears between 42 and 205 μm/d. The mean rates for each quadrant, measured clockwise from the 12 o'clock position, were 104.93, 89.80, 72.67, and 109.93 μm/d, respectively. The pathologic ears exhibited a rate between 88 and 140 μm/d, and at approximately 4 to 12 weeks after ink application, areas of abnormal desquamation were apparent at the inferior quadrant, leading to a halt in the migration of the ink dot once it reached these sites.
CONCLUSION: Epithelial migration occurred in an almost linear pattern in all quadrants, but the speed of migration was relatively slower in the anterior and inferior quadrants of a normal EAC. In the single KO patient, there were areas of normal migration and areas of abnormal keratin resurfacing at the inferior quadrant, which interfered with the migration of ink dots.
Fulltext Actinomyces infection of the mastoid: a rare entity

Subha ST, Raman R, Cheah PL, Soo Hoo TS

Med J Malaysia, 2004 Dec;59(5):680-1.
PMID: 15889574

A rare case of mastoid infection caused by actinomyces israelii is presented. This patient underwent exploratory mastoidectomy followed by long term oral pencillin. She responded well to the treatment and has been asymptomatic on follow up to date.
Nasopharyngeal carcinoma and nasal allergy: any correlation?

Prepageran N, Lingham OR, Krishnan G, Jalaludin MA, Raman R

Ear Nose Throat J, 2003 Jun;82(6):438-40.
PMID: 12861869

Although it has been observed that nasal allergy is rarely seen in patients who have nasopharyngeal carcinoma, to our knowledge, no actual study of such a lack of association has been previously reported. To fill this void, we conducted a pilot study to investigate any such inverse relationship. We conducted skin-prick allergen tests on 22 patients with newly diagnosed but not-yet-treated nasopharyngeal carcinoma. Combining these test results with findings on the history and clinical examination, we concluded that only one of the 22 cancer patients (4.5%) had allergic rhinitis. Our study also confirmed the validity of using findings on the history, clinical examination, and skin-prick testing as a reliable means of diagnosing allergic rhinitis.
Spontaneous sublingual hematoma as a complication of severe hypertension: first report of a case

Prepageran N, Raman R, Ismail SM, Rahman ZA

Ear Nose Throat J, 2002 Aug;81(8):576-8.
PMID: 12199178

We describe what we believe is the first reported case of a sublingual hematoma secondary to severe hypertension. The patient, a 77-year-old woman, experienced a spontaneous hematoma of the floor of the mouth, tongue, and sublingual space that eventually caused an airway obstruction. We performed an emergency tracheostomy under local anesthesia and then evacuated the hematoma through an incision along the floor of the mouth. The patient recovered uneventfully.
Fulltext Otological disorders in Down's Syndrome

Satwant S, Subramaniam KN, Prepageran N, Raman R, Jalaludin MA

Med J Malaysia, 2002 Sep;57(3):278-82.
PMID: 12440266

Objective: To assess if children with Down's Syndrome have a higher prevalence of otological abnormality compared to their normal counterparts in Malaysia.
Methodology: Thirty children with Down’s Syndrome and normal children underwent otoscope ear examination and impedance test in the ENT outpatients clinic in University Hospital Kuala Lumpur, Malaysia.
Results: The study showed that children with Down’s Syndrome had higher ontological disorders. Forty four percent had impacted wax compared to 14.4% in normal children. Twenty one percent of ears in the study group had refracted drums compared to 6.6% of control. Fifteen percent of ears in the study group had middle ear effusion compared to 3.4% in controls, 55% had a type B tympanogram compared to 8.3% in controls and 73.4% had auditory canal stenosis compared to 14.4% in controls.
Conclusion: Children with Down’s Syndrome thus have a higher incidence of ontological disorders.

Study site: ENT outpatient clincs, University Malaya Medical Centre (UMMC)
Effects of nasal lavage with and without mupirocin after endoscopic endonasal skull base surgery: a randomised, controlled study

Ng BHK, Tang IP, Narayanan P, Raman R, Carrau RL

J Laryngol Otol, 2019 Dec;133(12):1059-1063.
PMID: 31774052 DOI: 10.1017/S0022215119002329

BACKGROUND: Nasal lavage with mupirocin has the potential to reduce sinonasal morbidity in endoscopic endonasal approaches for skull base surgery.
OBJECTIVE: To evaluate the effects of nasal lavage with and without mupirocin after endoscopic endonasal skull base surgery.
METHODS: A pilot randomised, controlled trial was conducted on 20 adult patients who had undergone endoscopic endonasal approaches for skull base lesions. These patients were randomly assigned to cohorts using nasal lavages with mupirocin or without mupirocin. Patients were assessed in the out-patient clinic, one week and one month after surgery, using the 22-item Sino-Nasal Outcome Test questionnaire and nasal endoscopy.
RESULTS: Patients in the mupirocin nasal lavage group had lower nasal endoscopy scores post-operatively, and a statistically significant larger difference in nasal endoscopy scores at one month compared to one week. The mupirocin nasal lavage group also showed better Sino-Nasal Outcome Test scores at one month compared to the group without mupirocin.
CONCLUSION: Nasal lavage with mupirocin seems to yield better outcomes regarding patients' symptoms and endoscopic findings.
Fulltext Mucoepidermoid carcinoma of the nasal septum (case report)

Alazzawi S, Sivalingam S, Raman R, Mun KS

Ann Saudi Med, 2015 10 29;35(5):400-2.
PMID: 26506975 DOI: 10.5144/0256-4947.2015.400

We report an extremely rare case of mucoepidermoid carcinoma of the nasal septum. A patient with a history of right-sided nasal obstruction presented to our clinic. Clinical examination revealed a mass in the right nasal cavity originating from the nasal septum. Biopsy revealed a high-grade mucoepidermoid carcinoma. The patient was treated with surgical resection only. Surgery alone might be suitable for small tumors when direct inspection of the surgical site is feasible to detect early recurrence.
Fulltext Pneumatization of Mastoid Air Cells, Temporal Bone, Ethmoid and Sphenoid Sinuses. Any Correlation?

Hindi K, Alazzawi S, Raman R, Prepageran N, Rahmat K

Indian J Otolaryngol Head Neck Surg, 2014 Dec;66(4):429-36.
PMID: 26396957 DOI: 10.1007/s12070-014-0745-z

The aim of this study is to assess the pneumatization of the paranasal sinuses (PNS) and other parts of temporal bone such as mastoid air cells and to investigate if there was any association between the aeration of these structures among the three major ethnic groups in Malaysia (Malay, Chinese, Indian) as this would be representative of Asia. A retrospective review of 150 computed tomography (CT) scans of PNS and temporal bones was done and analysed. The pneumatization of each area was obtained and compared using statistical analysis. Patients with a history of previous medical or surgical problems in the intended areas were excluded from the study. The pneumatization of the mastoid air cells and other temporal bone parts were noted to be symmetrical in more than 75 %. There was a positive correlation between the pneumatization of mastoid air cells and that of the sphenoid sinus. The prevalence of Agger nasi, Haller's and Onodi cells was observed to be significantly higher in the Chinese group. Preoperative assessment of the temporal bone and PNS with CT scan may be helpful in the evaluation of their anatomical landmark and decrease the possibility of surgical complications related to 3D structures.
Fulltext High-frequency hearing loss among mobile phone users

Velayutham P, Govindasamy GK, Raman R, Prepageran N, Ng KH

Indian J Otolaryngol Head Neck Surg, 2014 Jan;66(Suppl 1):169-72.
PMID: 24533378 DOI: 10.1007/s12070-011-0406-4

The objective of this study is to assess high frequency hearing (above 8 kHz) loss among prolonged mobile phone users is a tertiary Referral Center. Prospective single blinded study. This is the first study that used high-frequency audiometry. The wide usage of mobile phone is so profound that we were unable to find enough non-users as a control group. Therefore we compared the non-dominant ear to the dominant ear using audiometric measurements. The study was a blinded study wherein the audiologist did not know which was the dominant ear. A total of 100 subjects were studied. Of the subjects studied 53% were males and 47% females. Mean age was 27. The left ear was dominant in 63%, 22% were dominant in the right ear and 15% did not have a preference. This study showed that there is significant loss in the dominant ear compared to the non-dominant ear (P
Fulltext Hypertensive retinopathy and sensorineural hearing loss

Tan TY, Rahmat O, Prepageran N, Fauzi A, Noran NH, Raman R

Indian J Otolaryngol Head Neck Surg, 2009 Dec;61(4):275-9.
PMID: 23120650 DOI: 10.1007/s12070-009-0082-9

To determine the correlation between hypertensive retinopathy (which is the end-organ damage of the vessels due to chronic hypertension) with sensorineural hearing loss.
An abnormal sigmoid sinus with a dire clinical implication

Puraviappan P, Prepageran N, Ong CA, Abd Karim R, Lingham OR, Raman R

Ear Nose Throat J, 2014 Jun;93(6):E55-6.
PMID: 24932833
Fulltext Mental Trauma Experienced by Caregivers of patients with Diffuse Axonal Injury or Severe Traumatic Brain Injury

Syed Hassan ST, Jamaludin H, Abd Raman R, Mohd Riji H, Wan Fei K

Trauma Mon, 2013 Sep;18(2):56-61.
PMID: 24350153 DOI: 10.5812/traumamon.11522

CONTEXT: As with care giving and rehabilitation in chronic illnesses, the concern with traumatic brain injury (TBI), particularly with diffuse axonal injury (DAI), is that the caregivers are so overwhelmingly involved in caring and rehabilitation of the victim that in the process they become traumatized themselves. This review intends to shed light on the hidden and silent trauma sustained by the caregivers of severe brain injury survivors. Motor vehicle accident (MVA) is the highest contributor of TBI or DAI. The essence of trauma is the infliction of pain and suffering and having to bear the pain (i.e. by the TBI survivor) and the burden of having to take care and manage and rehabilitate the TBI survivor (i.e. by the TBI caregiver). Moreover many caregivers are not trained for their care giving task, thus compounding the stress of care giving and rehabilitating patients. Most research on TBI including DAI, focus on the survivors and not on the caregivers. TBI injury and its effects and impacts remain the core question of most studies, which are largely based on the quantitative approach.
EVIDENCE ACQUISITION: Qualitative research can better assess human sufferings such as in the case of DAI trauma. While quantitative research can measure many psychometric parameters to assess some aspects of trauma conditions, qualitative research is able to fully reveal the meaning, ramification and experience of TBI trauma. Both care giving and rehabilitation are overwhelmingly demanding; hence , they may complicate the caregivers' stress. However, some positive outcomes also exist.
RESULTS: Caregivers involved in caring and rehabilitation of TBI victims may become mentally traumatized. Posttraumatic recovery of the TBI survivor can enhance the entire family's closeness and bonding as well as improve the mental status of the caregiver.
CONCLUSIONS: A long-term longitudinal study encompassing integrated research is needed to fully understand the traumatic experiences of caregivers. Unless research on TBI or DAI trauma is given its proper attention, the burden of trauma and injury on societies will continue to exacerbate globally.
Fulltext Oral care practice for the ventilated patients in intensive care units: a pilot survey

Soh KL, Shariff Ghazali S, Soh KG, Abdul Raman R, Sharif Abdullah SS, Ong SL

J Infect Dev Ctries, 2012 Apr;6(4):333-9.
PMID: 22505443

INTRODUCTION: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in intensive care units (ICUs). One factor causing VAP is aspiration of oral colonisation, which may result from poor oral care practice. Oral care using tooth brushing can prevent formulation of dental plaque that can be a reservoir for microbes causing VAP.
METHODOLOGY: A cross-sectional survey was conducted among 124 nurses, using a self-administered questionnaire, to determine methods used, frequency, and attitude of nurses toward oral care provided to mechanically ventilated patients in Malaysian ICUs.
RESULTS: Methods for oral care and their frequency of use varied between nurses even in the same unit. Cotton with forceps was used by 73.4% of the nurses. Some nurses used forceps and gauze (65%) or spatulas and gauze (36%). Toothbrushes were used by 50.8% of the nurses. Nurses in this hospital reported to have positive attitude toward providing oral care.
CONCLUSIONS: The survey showed the need to have standardised oral care protocols in ICUs to improve quality of oral care provided to ventilated patients.
Perception of intensive care unit stressors in Malaysian Federal Territory hospitals

Soh KL, Soh KG, Ahmad Z, Abdul Raman R, Japar S

Contemp Nurse, 2008 Dec;31(1):86-93.
PMID: 19117504

The Intensive Care Unit (ICU) is a therapeutic place for monitoring critically ill patients. However, it is a stressful area for the patients and it is causing them great anxiety. Previous studies have identified three groups of stressors in ICU namely; physical, psychological and environmental. The aims of this study were to determine the ICU stressors as experienced by patients and to determine the level of stressors felt by patients in ICU. A cross sectional study was done on 70 patients from two tertiary hospitals in Malaysia. A face-to-face interview with structured questionnaire was used for patients. Data collection occurred from 15 December 2006 to 31 January 2007. The five major ICU stressors perceived by patients were pain, being stuck with needles, boredom, missing their spouses and being too hot/cold. The ICU physical stressors were the major items ranked by post ICU patients. The findings from this study provided a set of baseline information to the health care providers, particularly ICU nurses in Malaysia, with which to provide better care for the patients in ICU.

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