Clinical experience in Endoscopic Endonasal Transpterygoid Nasopharyngectomy (EETN) in local residual or recurrent nasopharyngeal carcinoma

Introduction: Endoscopic endonasal transpterygoid nasopharyngectomy (EETN) has emerged as a viable treatment option for local residual or recurrent NPC. Multidisciplinary discussion is needed to determine patient’s eligibility for EETN. The factors that exclude patients from EETN surgery include extensive involvement of parapharyngeal space, internal carotid artery, cavernous sinus with multiple cranial nerve palsies, extension into brain parenchymal and presence of distant metastasis. The surgery is purely via endoscope with four hands technique. Adequate sinonasal corridor with extended medial maxillectomy and posterior septectomy is crucial to have panoramic view of the field of surgery. Methods: A retrospective clinical record review was carried out for EETN cases done in Sarawak General Hospital from June 2013 till May 2017. Results: A total of 55 locally recurrent NPC patients (rT1–rT4) underwent EETN with curative intent performed by single skull base surgeon, with postoperative adjuvant chemotherapy but without postoperative radiotherapy. There were no major postoperative complications. During a mean follow-up period of 18-month post-surgery, five patients (9.1%) had residual disease 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%. Conclusion: EETN is an emerging treatment option for locally recurrent NPC, with relatively low morbidity and encouraging short-term outcome. However, successful surgical outcome requires an experienced team and highly s

Comparison of distortion product otoacoustic emission (DPOAE) and automated auditory brainstem response (AABR) for neonatal hearing screening in a hospital with high delivery rate

Introduction: Congenital hearing loss is one of the commonest congenital anomalies. Neonatal hearing screening aims to detect congenital hearing loss early and provide prompt intervention for better speech and language development. The two recommended methods for neonatal hearing screening are otoacoustic emission (OAE) and automated auditory brainstem response (AABR). Objective: To study the effectiveness of distortion product otoacoustic emission (DPOAE) and automated auditory brainstem response (AABR) as first screening tool among non-risk newborns in a hospital with high delivery rate. Method: A total of 722 non-risk newborns (1444 ears) were screened with both DPOAE and AABR prior to discharge within one month. Babies who failed AABR were rescreened with AABR ± diagnostic auditory brainstem response tests within one month of age. Results: The pass rate for AABR (67.9%) was higher than DPOAE (50.1%). Both DPOAE and AABR pass rates improved significantly with increasing age (p-value<0.001). The highest pass rate for both DPOAE and AABR were between the age of 36–48 h, 73.1% and 84.2% respectively. The mean testing time for AABR (13.54 min ± 7.47) was significantly longer than DPOAE (3.52 min ± 1.87), with a p-value of <0.001. Conclusions: OAE test is faster and easier than AABR, but with higher false positive rate. The most ideal hearing screening protocol should be tailored according to different centre

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

Transoral excision of retropharyngeal schwannoma: Case report

Schwannoma is a benign nerve sheath tumor that arises from neural crest-derived Schwann cells. They are well-circumscribed and encapsulated tumor, commonly seen over the cervical region that involves the cervical and brachial plexus. However, the existence of this benign tumor in retropharyngeal space is infrequent. We report a case where a patient presented with incidental findings of retropharyngeal schwannoma, who is treated with trans-oral excision with tumor completely excised and patient recovered completely post-operative

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

Sinonasal angioleiomyoma

Angioleiomyoma of the nasal cavity is an extremely rare benign neoplasm. It usually occurs in the lower extremities. Up to date, only few cases of angioleiomyoma have been reported. First case of angioleiomyoma of nasal cavity was reported in 1966. We report a rare case of angioleiomyoma arising from the right maxillary sinus. Case Report: A 43-year-old lady presented with recurrent epistaxis and right nasal obstruction for two months duration. Clinical examination revealed a huge right nasal mass obstructing the right nasal cavity. The tumour was excised completely via endoscopic endonasal surgical approach. Histopathological examination confirmed the tumour is sinonasal angioleiomyoma. Postoperatively, she recovered well without any recurrence after a year of followup. Conclusion: This tumour has an excellent prognosis and recurrence is extremely rare if excised completely

Carotid Blow-out syndrome: Challenges in management of epistaxis in a post-surgical intervention and radiated patient

Recurrent epistaxis is a red flag in post-nasal surgery and previously radiated cancer patients. The incidence of carotid blow-out syndrome is seven times higher in previously radiated patients. Today, nasal endoscopy has become an essential tool in our practice. It helps in identifying the source of bleeding and facilitates therapeutic management. On the other hand, radio imaging is highly sensitive and specific to detect vascular lesions. However, they are not perfect. This paper presents a treated sphenoid sinus carcinoma patient with the right internal carotid thrombosis who presented with sentinel epistaxis. Endoscopic nasal examination and radio imaging failed to identify the bleeder and misled to a wrong source of bleeding. The bleeder was finally detected via the examination under anaesthesia (EUA). The carotid blowout occurred intraoperatively. Management of this patient is extra challenging as the blow-out vessel was the only major blood supply to the anterior cerebral circulation. The haemostasis was secured with a muscular patch and a vascular stent inserted. He was free from the neurological deficit. Unfortunately, profuse epistaxis recurred on post-operative day five. Although nasal packing controlled his recurrent epistaxis, he developed anterior circulation infarct later on and succumbed to death. The authors wish to highlight the importance of EUA if radio imaging does not correlate to the clinical findings. Management options for carotid blow-out should tailor to the patients’ medical conditions

A five-year experience in endoscopic endonasal excision of juvenile nasopharyngeal angiofibroma

Introduction: Juvenile nasopharyngeal angiofibroma (JNA) is a histological benign but locally aggressive vascular tumour which can invade the base of skull. Aim: This is a retrospective study with the aim to examine the outcome of patients with JNA and endoscopic endonasal excision of tumour at a tertiary center in Malaysia. Material and methods: 9 patients were identified from the medical record office from 2015 to 2019. We review the data on patient demographics, clinical presentations, laboratory investigations, intraoperative blood loss and duration of hospital stay. Results and discussion: 8 patients were male, 1 was female. The average age of diagnosis was 15 (range 11 to 29) years. The commonest chief complaint was recurrent epistaxis, followed by nasal obstruction and nasal discharge. Three patients were at stage I, 4 patients at stage II, 1 patient at stage III and 1 patient at stage IV based on Fisch classification. All patients underwent primary endoscopic endonasal excision of tumour with no vascular, ophthalmological or neurological complication. Seven patients had preoperative embolization done. Average operation time was 137 minutes (range 60–360 minutes). Intraoperative blood lost varied from 500 mL to 1300 mL (mean 777.7 mL). All patients were discharged well with no recurrence. Conclusions: The management of JNA can be challenging. The current shift in management favouring endoscopic endonasal excision of JNA reduces postoperative morbidity. It is possible to be applied on all stages of tumour with good success rate

Outcomes of canal wall down mastoidectomy in cholesteatoma : a 5-year experience

Background Cholesteatoma is an atticoantral disease that potentially causes life-threatening complications. Therefore, canal wall down mastoidectomy is a well-established technique to eradicate the disease, especially in extensive cholesteatoma. Aim To evaluate the status of dry ear and hearing outcome post-retrograde canal wall down mastoidectomy. Methods A retrospective study of patients with cholesteatoma who underwent modifed radical mastoidectomy (MRM), a form of canal wall down mastoidectomy between January 2014 and December 2018. Results Fifty-seven patients were included with a mean age of 40 years. The majority of cases were adults, 86%, and 14% were children. Most of them complained of ear discharge (73.7%), followed by hearing loss (31.6%). Intraoperatively, cholesteatoma was primarily found in cases involving mastoid air cells, antrum, attic, and mesotympanum (47.4%). The presence of granulation tissue with cholesteatoma was noted in 57.9% of cases. Furthermore, 73.7 % of ossicular chain erosion cases involved erosion of all ossicles (47.6 %). In 26.3 % of cases, tegmen erosion was identifed. Facial canal dehiscence accounted for 15.8% of MRM cases, sclerotic mastoid was noted for 10.5%, and lateral semicircular canal dehiscence involved 5.3%. Up to 3 months of follow-up post-MRM showed 70.2% had a dry ear. After 6 months, there were 15.8% complaints of ear discharge in the subsequent follow-up. In this study, 33 out of 57 patients underwent a postoperative hearing evaluation, and 21.2 % of patients showed an improvement in the air-bone gap. Conclusion Canal wall down mastoidectomy is a treatment of choice in extensive cholesteatoma to achieve a dry and safe ear with maintaining functional hearing outcomes