Endoscopic transsphenoidal resection of craniopharyngioma

Objectives: To demonstrate, step-by-step, the technique and efficacy of endoscopic transsphenoidal approach in resection of a suprasellar craniopharyngioma. Design The video shows a step-by-step approach to the resection, covering the exposure, access, resection, and confirmation of resection and reconstruction. Setting: The surgery was performed in the University of Malaya Medical Centre, a tertiary referral center in the capital of Malaysia. Participants Surgery was performed jointly by Professor Prepageran from the department of otorhinolaryngology and Professor Vicknes Waran from the division of neurosurgery. Both surgeons are from the University of Malaya. Video compilation, editing, and voice narration was done by Dr. Kong Yew Liew. Main Outcome Measures: Completeness of resection and avoidance of intra- and postoperative complications. Results: Based on intraoperative views and MRI findings, the tumor was completely resected with the patient suffering only transient diabetes insipidus. Conclusion: Central suprasellar tumors can be removed completely via an endoscopic transsphenoidal approach with minimal morbidity to the patient

Dentigerous cyst of the maxillary sinus in a child.

Dentigerous cyst in maxillary sinus, especially in children, is uncommon in Malaysia. Few cases of dentigerous cyst in maxillary sinus in children have been reported in the medical literature. According to Tay AB et al, dentigerous cyst was accounted for 2.3% of the 20 most common diagnosed oral tumors in Singapore form year 1993-19971. This report illustrates a case of the dentigerous cyst in the maxillary sinus, resulting in significant facial swelling, which was managed by endoscopic marsupialization of the cyst

Association between Ocular Pseudoexfoliation and Sensorineural Hearing Loss

Background. Our study aimed to investigate an association between ocular pseudoexfoliation (PXF) and sensorineural hearing loss (SNHL) and to compare them with age and sex matched controls without pseudoexfoliation. Method. This was a case-control study of 123 patients which included 68 cases with PXF (at least one eye) and 55 controls without pseudoexfoliation. Pure-tone audiometry (PTA) was done for these patients at sound frequencies taken as important for speech comprehension, that is, 250 Hertz (Hz), 500 Hz, 1000 Hz, and 2000 Hz. Results. There were 41 patients with pseudoexfoliation syndrome (PXE) and 27 with pseudoexfoliative glaucoma (PXEG). The majority of patients with hearing loss (60%; n=51) were PXF patients and the remaining 40% (n=34) were controls. Below average hearing thresholds were significantly higher in the pseudoexfoliation group compared to the control group (P=0.01; odds ratio (OR), 3.00; 95% confidence interval (CI), 1.25–7.19). However, there was no significant difference in the mean hearing threshold levels between the three groups (PXE, PXEG, and controls) in either ear (ANOVA, right ear: P=0.46 and left ear P=0.36). Conclusion. Our study found an association between PXF and SNHL, confirming that PXF can involve organs in the body other than the eye

Can bone wax cause cholesterol granuloma in the petrous apex? A case report

BACKGROUND: Cholesterol granuloma (CG) is a rare entity but is the commonest lesion in the petrous apex. They are associated with chronic ear disease and previous temporal bone surgery. While bone wax has been known to cause foreign body reaction due to its non-resorbable property in the mastoid, it has not been documented to cause CG formation. CASE PRESENTATION: We described a 43 years old male who presented with a right mastoid swelling, nine years after a right retro-sigmoid craniotomy and excision for a cerebellopontine angle meningioma. He also had multiple cranial neuropathies involving trigeminal, facial and vestibulocochlear nerves. Temporal bone CT and MRI showed features suggestive of cholesterol granuloma with extensive bony erosions. He was treated with surgical excision and drainage where bone wax residues were found intraoperatively. Histopathological analysis of the lesion confirmed the diagnosis of cholesterol granuloma. Post-operatively, the mastoid swelling resolved and his recovery was uneventful. CONCLUSION: Our case showed that CG could manifest as a complication of bone wax usage in a neurosurgical procedure. Even though further study is needed to draw a definitive conclusion on this theory, we believe this paper will contribute to the current literature as it is the only reported case of cholesterol granuloma with bone wax as the possible causative agent. This is important so that surgeons are aware of this potential complication and use this haemostatic agent more judiciously

Surgical anatomy of the nasopharynx

This chapter introduces the surgical anatomy of the nasopharynx. Surgical anatomy of the nasopharynx is important for understanding nasopharyngeal diseases, especially malignancy. As the anatomy at this region is complicated and involves many important structures, great care should be emphasized. This chapter describes the anatomy of nasopharynx with a focus on important surgical landmarks

Clinical Study Association between Ocular Pseudoexfoliation and Sensorineural Hearing Loss

Background. Our study aimed to investigate an association between ocular pseudoexfoliation (PXF) and sensorineural hearing loss (SNHL) and to compare them with age and sex matched controls without pseudoexfoliation. Method. This was a case-control study of 123 patients which included 68 cases with PXF (at least one eye) and 55 controls without pseudoexfoliation. Pure-tone audiometry (PTA) was done for these patients at sound frequencies taken as important for speech comprehension, that is, 250 Hertz (Hz), 500 Hz, 1000 Hz, and 2000 Hz. Results. There were 41 patients with pseudoexfoliation syndrome (PXE) and 27 with pseudoexfoliative glaucoma (PXEG). The majority of patients with hearing loss (60%; = 51) were PXF patients and the remaining 40% ( = 34) were controls. Below average hearing thresholds were significantly higher in the pseudoexfoliation group compared to the control group ( = 0.01; odds ratio (OR), 3.00; 95% confidence interval (CI), 1.25-7.19). However, there was no significant difference in the mean hearing threshold levels between the three groups (PXE, PXEG, and controls) in either ear (ANOVA, right ear: = 0.46 and left ear = 0.36). Conclusion. Our study found an association between PXF and SNHL, confirming that PXF can involve organs in the body other than the eye. Background Pseudoexfoliation (PXF) is an age-related systemic condition characterized by the production and accumulation of abnormal fibrillar extracellular material Ocular pseudoexfoliation is now recognized as a systemic disease as these materials have been found in other parts of the body, namely, the skin, vascular structures, and visceral organs such as the kidney, heart, lungs, and gall bladder as well as in the inner ear The inner ear is a complex organ. The tectorial and basilar membranes of the inner ear, like the anterior segment structures of the eye, are derived from the neural ectoderm. PXE material has been found on the tectorial and basilar membrane of the inner ear in some studies Normal hearing threshold levels in humans are 0-20 dB, where dB (decibel) is the logarithmic unit of sound pressure which implies loudness of sound energy Although all frequencies in the range 250-4000 Hz are relevant for speech comprehension, we have chosen four Many studies have been done to find the association of sensorineural hearing loss among pseudoexfoliation patients using speech frequencies of 1000 Hz, 2000 Hz, and 3000 Hz Methods and Materials In this case-control study, all patients who had ocular pseudoexfoliation (syndrome (PXE) or glaucoma (PXEG)) were referred to as the case group and those without pseudoexfoliation as controls. The time frame of the study was from June 2011 to May 2012. All enrolled patients were sent to the otorhinolaryngology clinic for otologic testing and hearing assessment for frequency levels 250 Hz, 500 Hz, 1000 Hz, and 2000 Hz Inclusion criteria for case group were male and female adults diagnosed with PXE syndrome or glaucoma in either eye, while the control group was patients without ocular pseudoexfoliation matched for age and gender. Exclusion criteria include patients with any other type of secondary glaucoma other than pseudoexfoliation glaucoma or any ocular or systemic condition having hearing or ear associations. Furthermore patients with history of ear infection, surgery, tympanic membrane perforation, exposure to ototoxic drugs or heavy noise, and upper respiratory tract infection during examination were excluded. Approval of the ethics committee was obtained from the Ethics Committee of University, Malaya Medical Centre and National Medical Research Registry of Kementerian Kesihatan Malaysia. A full ophthalmic examination including slit lamp biomicroscopy, gonioscopy (Shaffer), applanation tonometry, pupil dilation, and fundus examination was done. Patients were examined for the presence of PXF (white dandruff-like material) in the pupillary margin on undilated pupils and anterior lens capsule with dilated pupils while the presence of PXF on the trabecular meshwork on gonioscopy was also checked. A Humphrey visual field test for the patients was done. Patients were then sent for otologic examination at the ENT clinic. Hearing assessment (pure tone audiometry) was performed by the audiologist. Statistical Analysis. Tracing of the data was done after completion of the hearing assessment and analyzed using SPSS version 17.00. A significance level of = 0.05 was used for all statistical inferences. Hence, a value <0.05 will indicate a significant result. Hearing threshold levels in dB were graded according to severity (normal to profound) and each ear was analyzed separately Results A total of 123 patients were studied, including 68 patients in the ocular pseudoexfoliation group (PXF) and 55 patients in control group. The mean age for the pseudoexfoliation group was 68.5 ± 7.8 years (Mean ± standard deviation) while mean age for the control group was 66.3 ± 7.4. There were 48 male and 75 female patients in the study. Patients with PXF were most commonly found in the age group of 60-69. Ocular pseudoexfoliation was seen predominantly in females ( = 43, 63.23%) in the PXF group. The males had almost equal distribution in both groups. The number of female patients in the PXF group was nearly double the male patients (Pearson, Chi square, = 0.56). The ratio of male to female patients in the PXF group was 1 : 1.7 and in the control group was 1 : 1.4. There was no significant relation found between gender and hearing loss ( = 0.1, odds ratio: 0.5, 95% CI (0.2, 1.3)). The mean IOP was significantly higher in the pseudoexfoliation glaucoma group (right eye: 15.77 mmHg 95% CI (13.87, 17.68); left eye 15.96 mmHg 95% CI (14.03, 17.89)) compared with the control group ( = 0.004 for right eye and < 0.001 for the left eye) and left eye in the pseudoexfoliation syndrome group ( = 0.07 for the right eye and = 0.004 for the left eye) (ANOVA, Tukey Post Hoc Test). 39.7% ( = 27) of patients with pseudoexfoliation had pseudoexfoliative glaucoma. All patients with PXEG were receiving antiglaucoma medication. A total of 115 of 123 patients (93.5%) in the pseudoexfoliation and control groups were analyzed for sensorineural hearing loss. Six patients had missing data and 2 patients were excluded due to ear pathology. Overall, 73.9% ( = 85) had sensorineural hearing loss. Among the 85 patients with hearing loss, 60% ( = 51) were pseudoexfoliation patients and the remaining 40% were controls. More than 75% of patients in both groups had bilateral sensorineural hearing loss. Patients below average hearing thresholds at speech presentation level were significantly higher in the pseudoexfoliation group compared to the control group ( = 0

Endoscopic sinus surgery training courses: Benefit and problems – a multicenter evaluation

Introduction: Dissection courses are important for trainees and surgeons in mastering the skills required to perform endoscopic sinus surgery (ESS) which is a common surgery in otorhinolaryngology. Aim: To evaluate the benefits of ESS training courses and ways to improve training. Material and methods: In a prospective study using a structured questionnaire, participants of ESS courses in the United Kingdom, Malaysia, India and Thailand were asked on their experiences in these courses and suggestions on improving them. Results and discussion: The majority of the participants have experiences in performing ESS prior to joining the course. Infundibulotomy was considered the easiest dissection step in ESS while frontal sinus surgery was considered the most challenging by the majority of the participants. The motivation for most of the participants in joining the course is to improve their skills with almost all stating that their expectations of the course have been fulfilled with improvement of their surgical techniques, anatomical skills and on patient’s safety. Almost all the participants were satisfied with the course and would recommend attending it. Conclusions: ESS dissection courses are an integral part in the learning process of trainees in becoming a competent surgeon and for surgeons to improve their techniques. Continuous improvement should be made to ensure that the participants will benefit from attending the cours