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.
The duodenum is the most common site of cholecystoenteric fistulation resulting from cholecystitis or empyema of the gallbladder. This rare condition is usually only diagnosed intraoperatively and managed incidentally. This paper presents the endoscopic diagnosis of a case of cholecystoduodenal fistula arising from the late presentation of empyema of the gallbladder and its subsequent drainage through the fistula. As far as we can determine, this is the only reported case of opportunistic drainage of an empyema of the gallbladder through a concurrent cholecystoduodenal fistula.
Reported cases of acquired posterior choanal atresia are very few in the English literature. A case of acquired posterior choanal atresia post radiotherapy is reported which was treated by endonasal endoscopic repair using microdebrider with untoward effect.
Choana atresia is a congenital abnormality of the posterior nasal apertures affecting the newborn. The aetiology is considered to be a persistence of the embroyological bucconasal membrane which separates the nasal cavity from the stomatodeum until it breaks down at seventh week, allowing communication through the primitive posterior nares. Bilateral choanal atresia almost always present as a respiratory emergency because newborn babies are obligate nasal breathers. The definitive surgical treatment is repair under general anaesthesia. We report our experience in doing a new technique of transnasal endoscopic repair.
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.
Intranasal haemangioma is quite rare. This tumor may be confused with other intranasal vascular tumor such as juvenile nasopharyngeal angiofibroma (JNA), glomus tumors as well as other tumor such as angiosarcoma and leiomyoma. Juvenile nasopharyngeal angiofibroma is the most common vascular tumor encountered in nasal cavity. A definitive histology diagnosis pre-operatively is difficult to be obtained as the biopsy may lead into severe uncontrolled bleeding. The final diagnosis very much depends on histology after the tumor excision. Complete surgical resection of the tumor is the standard approach. In this report we describe our surgical management in approaching intranasal haemangioma endoscopically and this pathology can be considered as one of differential diagnosis for unilateral nasal mass.
Craniofacial resection is commonly performed in the surgical resection of sinonasal tumours involving anterior skull base. It entails a bicoronal scalp flap with lateral rhinotomy or an extended lateral rhinotomy to expose the anterior skull base. Transfacial approach is necessary in the resection of the nasal part of the tumour. The choice of surgical approach is based heavily on the surgeon's experience and training. The results of endoscopic-assisted craniofacial resection for sinonasal tumours performed in our center in eight patients from 1998 to 2005 were reviewed. There were seven males and one female with age ranging from 18 to 62 years (mean 42.4 years). There was each a case of mature teratoma, poorly differentiated squamous cell carcinoma, undifferentiated squamous cell carcinoma, olfactory neuroblastoma, fibrous dysplasia, inverted papilloma and two cases of sinonasal neuroendocrine carcinoma. The mean follow up duration for these eight patients post surgery was 21.4 months. Out of eight patients, five underwent surgery with no adverse complications. The complications encountered were a cerebrospinal leak and a postoperative transient V and VI cranial nerve palsy. One patient with sinonasal undifferentiated carcinoma died of lung metastasis at 11 months post-surgery. The endoscopic-assisted craniofacial resection is a highly useful surgical technique to avoid the unsightly facial scar of the lateral rhinotomy or the Weber-Ferguson incision, postoperative paranasal sinuses infection and avoidance of tracheostomy in selected cases. We found that this approach has lower morbidity rate in selected cases.
Although well established in the West, stool antigen tests (SAT) are not widely used in Asia. Data on the accuracy of this test in Asia is sparse and, to date, there have been no studies looking at the more refined monoclonal SAT. The aim of this study is to validate the diagnostic accuracy of a stool antigen test, Hp STAR, for the detection of Helicobacter pylori.
Percutaneous endoscopic spinal surgery performed in the awake state offers a new paradigm for treatment of symptomatic lumbar disc prolapse. We report the outcome of 23 patients who underwent this procedure. Visual analogue scale for pain improved from 7.3 to 2.1; 19 of the 23 patients achieved good to excellent results according to the MacNab criteria. Patient acceptance of the procedure was 91.3%. All but one patient were discharged from hospital within 24 hours. One patient developed foot drop post-operatively. There was no incidence of dural tear, post-operative infection or worsening of symptoms. We conclude that this is a safe, effective, and well-tolerated procedure.
The current advents of endoscopic techniques have enabled rhinologists to treat inverted papilloma of the nose with a more favourable surgical morbidity. However the supposed changing trend in surgical management of sinonasal inverted papilloma from external approach to endoscopic technique has to come with caution as certain guidelines must be made to ensure its effectiveness. Since the introduction of purely transnasal endoscopic medial maxillectomy in 1981, many authors have published their experiences in this field. This article reviews some of the literatures regarding the management aspect of inverted papilloma particularly focusing on the endoscopic medial maxillectomy and relate with our own experience in management of this tumour endoscopically.
Inverted papillomas (IPs), although histologically benign, are aggressive lesions that may recur after excision. They usually present as unilateral firm, bulky, red and vascular masses. The objective of this case series is to discuss the surgical treatment options for IPs and to review the literature with a special emphasis on our experience with endoscopic medial maxillectomy. A retrospective review of the data of patients with IP treated by endoscopic medial maxillectomy was performed. This report describes the surgical experience with five patients with IP arising from various sites on the lateral nasal wall. Data points collected included age, sex, location(s) and histopathological diagnosis (benign IP vs IP with dysplasia or carcinoma). The surgical treatment strategy, need for adjunct approaches, complications, recurrence rates and length of follow-up were determined. The average age was 51.2 years (range, 35-62 years), with four males and one female. All cases were managed with endoscopic medial maxillectomy as the primary surgical modality. Adjunctive approaches included endoscopic dacryocystorhinostomy (EDCR) in two patients who presented with epiphora post-operatively. Intra-operative frozen section was performed in all cases to ensure complete tumor removal. No intra-operative complications were encountered. No recurrences were noted in these patients, with a mean follow-up period of 23 months.
Historically, the recommended treatment for paranasal sinus mucoceles is the complete excision of through an open approach to achieve a cure. Though with the advent of Endoscopic sinus surgery, transnasal Endoscopic sinus surgery has gained more attention in order to manage the sinus mucocele. The aim of this study is to present the efficacy of the Endoscopic marsupialization of sinus mucoceles. From 2001 to 2005, 18 patients with paranasal sinus mucoceles were treated endoscopically. This series includes 6 fronto-ethmoidal, 2 maxillary, 4 ethmoid, 2 sphenoid, and 4 middle turbinate. The presenting signs, symptoms, and radiological findings were reviewed. All patients underwent endoscopic-wide marsupialization of the mucocele; the mean follow up was 13 months. There are 10 male and 8 female subjects who were of an age range of 29-72 years. Patients were treated with endoscopic marsupialization of the mucocele. There were no recurrences in the mean 13-month follow-ups in 17(94%) of patients. Only one patient needed revision endoscopic surgery. Mucocele happens to be the most commonly benign lesion, which causes the paranasal sinus to expand. There is increasing evidence that endoscopic marsupialization of sinus mucocele results in long-term control with very low recurrence rate at or close to 0%. Thus this technique is safe and less invasive than external approaches.
We report a male patient of Graves' Disease with bilateral exophthalmos who had undergone bilateral transnasal endoscopic orbital decompression with subsequent improvement of 3 mm in orbital proptosis bilaterally without any complications. Transnasal endoscopic orbital decompression is recommended as an alternative to traditional decompression techniques especially for purely cosmetic reasons.
Adenoidectomy is a common ENT procedure performed in hospitals in Malaysia. Adenoidectomy is indicated in patients with recurrent adenoiditis, nasal obstruction or sleep apnoea secondary to adenoid hypertrophy when conservative management has failed. Over the years, there are advances in the techniques of adenoidectomy, from the conventional transoral to endoscopic transnasal/transoral adenoidectomy. The purpose of this article is to describe the technique and emphasize the advantages of this procedure to that of the conventional technique.
A review of 45 patients who underwent endoscopic dacryocystorhinostomy (EDCR) from 1998 to 2005 was done. Only patients who had complete notes and had Jones tube removed at least three months before the study were included. Our experience with EDCR concludes it to be an easy, efficient treatment for nasolacrimal duct obstruction with minimal complications.
Anticoagulation and antiplatelet medications may potentiate GI bleeding, and their use may lead to an increased need for a GI endoscopy. We hypothesized that there might be different practice patterns among international endoscopists.
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.
This is a cross sectional study of 40 patients diagnosed with chronic rhinosinusitis using the Lanza Kennedy diagnostic criteria based on nasal endoscopy (NE), and on computer tomography (CT) of the paranasal sinuses. The purpose of the study is to demonstrate the effectiveness and limitations of CT, and NE in the assessment of chronic rhinosinusitis. This study shows that CT was superior in detecting OMC involvement, presence of concha bullosa, paradoxical turbinate and nasal septal deviation. NE was better at detecting polyps.