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BACKGROUND: Persistent Postural-Perceptual Dizziness (PPPD) is a chronic functional disorder which interferes with the way individuals experience their personal, social and work life. OBJECTIVE: To study the impact of disease duration in PPPD on the quality of life (QOL), dizziness handicap and mental health on the patients. METHODS: A prospective study comparing the EQ-5D for QOL, Dizziness Handicap Inventory (DHI) and DASS-21 between 27 patients with PPPD and 27 of those who have recovered from an acute vestibular event. Similar parameters between PPPD patients with symptoms less than one year and more than a year were compared. RESULTS: The PPPD patients were predominantly females and middle-aged with significantly higher DHI scores (mean 48.3 + 25.7, p = 0.00002), higher total mean scores in the DASS-21 (mean 21.6 + 13.7, p = 0.009) and poorer QOL with mean EQ-5D VAS of 67.9 + 17.3 (p < 0.00001). PPPD patients with symptoms for more than a year had significant increase in physical handicap (p = 0.041) as well as anxiety levels (p = 0.008). CONCLUSIONS: PPPD is predominantly seen in females and middle-aged which significantly reduces the QOL, increases dizziness handicap and increases depression, anxiety and stress levels. The increase in duration of illness further increases the anxiety levels and physical handicap. [ABSTRACT FROM AUTHOR]

We report a case of primary extracranial meningioma arising from the hypoglossal nerve in a 54-year-old man who presented with a 9-month history of hoarseness and progressive dysphagia. He had also noticed that his tongue was deviated to the left and, as a result, he was having difficulty pronouncing words. Examination revealed fasciculation and muscle wasting on the left side of the tongue. Other cranial nerve functions were normal. Contrast-enhanced computed tomography detected a heterogeneous mass that had arisen above the bifurcation of the left common carotid artery and had extended to near the skull base. Transcervical excision of the tumor was performed, and histopathology identified it as a meningioma of the hypoglossal nerve. The patient recovered uneventfully, and he was without recurrence at more than 2 years of follow-up. A primary extracranial meningioma is extremely rare, and its presentation may be subtle. A thorough investigation is necessary to avoid fatal compressive symptoms. [ABSTRACT FROM AUTHOR]

Objective: The global healthcare system was severely impacted by the coronavirus disease 2019 (COVID-19). Healthcare professionals, especially doctors, faced a tremendous amount of responsibility irrespective of the specialty and levels of experience. The majority of nations saw physicians from all medical specialties relocate to COVID-19 wards. Working outside of one's comfort zone would have a significant psychosocial impact, especially in a crisis like the pandemic. To describe the experience of noninfectious disease physicians redeployed to COVID-19 duties. Materials and Methods: All noninfectious disease physicians who were redeployed to COVID-19 duties received a Google form with 25 questions. Using the Pearson chi-squared test and the Fisher exact test, the relationship between survey responses and working experience and department was investigated. Statistical threshold was set at p<0.05. Results: Out of 180 respondents, 114 completed the survey in total. Most of the participants were female (64.9%) aged between 31--40 years old (86.8%) with 64.9% having 5--10 years of working experience. During the redeployment, 57% of respondents reported experiencing psychological effects, and 73.7% felt underprepared. However, 71.1% said their assignment to COVID-19 wards was beneficial, and 38.4% were willing to receive redeployment. Conclusion: The results of the survey indicate that COVID-19 ward redeployment was successful because participants believed their participation was important and the lead team in the COVID-19 wards offered enough direction and assistance. Doctors are prepared to safely treat COVID-19 patients, thanks to the intensive crash course and their fundamental medical knowledge. [ABSTRACT FROM AUTHOR]

Conclusion Symptomatic high frequency/acceleration vestibular loss is a distinct clinical entity that can be missed on conventional ENG with caloric testing. Under certain circumstances, symptomatic patients with a high frequency/acceleration vestibular loss should undergo an MSSC study for confirmation, if required. Objective To document that normal electronystagmography (ENG) with conventional bithermal caloric testing is inadequate for diagnosing clinically significant high frequency/acceleration vestibular loss. Material and methods Patients with clinical symptoms and signs of persistent peripheral vestibular dysfunction despite normal conventional bithermal caloric testing on ENG underwent high frequency/acceleration horizontal magnetic scleral search coil (MSSC) eye movement studies. The clinical findings and results from audiometric tests, conventional ENG with bithermal caloric tests and MSSC tests were reviewed. Results Eleven patients were identified as having an abnormal MSSC study, indicating a high frequency/acceleration vestibular loss consistent with their clinical history despite normal or equivocal bithermal caloric responses on conventional ENG. Although valuable, ENG caloric testing evaluates lateral semicircular canal function and should be considered a non-physiological test primarily of low frequency vestibular function. High frequency/acceleration head thrust testing clinically detected a "high frequency/acceleration vestibular loss" in 8/11(72.7%) cases. [ABSTRACT FROM AUTHOR]

We report the first case series utilizing the exoscope exclusively for bilateral simultaneous cochlear implant surgery and discuss the advantages, disadvantages, as well as surgical outcomes in the Covid-19 era. The VITOM® 2D is compatible with enhanced PPE and draping techniques which can improve safety while providing comparable surgical outcomes. [ABSTRACT FROM AUTHOR]

We report the rare occurrence of bilateral asymmetrical mucoceles of the paranasal sinuses that resulted in a unilateral orbital complication. Th e patient was a 47-year-old woman who presented with complaints of diplopia, blurred vision, and protrusion of her right eye that had progressed over a period of several months following an upper respiratory tract infection. Computed tomography detected the presence of two large, asymmetrical mucoceles. Th e lesion on the right involved the frontal and ethmoid sinuses, and the one on the left involved the ethmoid sinus. The mucoceles were locally expansile and had eroded the surrounding bony structures on the right. The expansile nature of the right-sided mass had displaced the right orbit, which was the cause of the vision deterioration. Transnasal endoscopic surgery was performed to excise and marsupialize the mucoceles. This modality was preferred over conventional open surgery because it affords good visualization, it is safe, and it is a less morbid procedure. Th e patient’s recovery was uneventful, and she was discharged home on the third postoperative day. On continuing follow-up, her vision had improved, her intraocular pressure had returned to normal, and her orbits were in their normal position. Based on our literature search, no case of bilateral frontal and ethmoid sinus mucoceles has been previously reported. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: Paediatric vestibular and balance services have recently gained attention across the globe. We present our one-year experience exploring the aetiology of paediatric vestibular disorders in a recently established Paediatric vestibular and balance clinic.Children and adolescents under 18 referred to the Paediatric Vestibular and Balance Clinic for evaluation were included.74 children were included in this study (Mean age: 10.04 ± 3.9). We found a slight female predominance, n = 38 (51.35%). Abnormal vestibular function was observed in 60.8% of children. Vestibular migraine (VM) was the most common aetiologic cause, n = 35 (47.3%), followed by vestibular/balance delay (n = 11).The most prevalent cause of dizziness was VM, followed by vestibular delay found in children with isolated speech and language delay. We highlight the importance of awareness of various causes of dizziness in children amongst carers and physicians to diagnose and manage it early.Methods: Paediatric vestibular and balance services have recently gained attention across the globe. We present our one-year experience exploring the aetiology of paediatric vestibular disorders in a recently established Paediatric vestibular and balance clinic.Children and adolescents under 18 referred to the Paediatric Vestibular and Balance Clinic for evaluation were included.74 children were included in this study (Mean age: 10.04 ± 3.9). We found a slight female predominance, n = 38 (51.35%). Abnormal vestibular function was observed in 60.8% of children. Vestibular migraine (VM) was the most common aetiologic cause, n = 35 (47.3%), followed by vestibular/balance delay (n = 11).The most prevalent cause of dizziness was VM, followed by vestibular delay found in children with isolated speech and language delay. We highlight the importance of awareness of various causes of dizziness in children amongst carers and physicians to diagnose and manage it early.Results: Paediatric vestibular and balance services have recently gained attention across the globe. We present our one-year experience exploring the aetiology of paediatric vestibular disorders in a recently established Paediatric vestibular and balance clinic.Children and adolescents under 18 referred to the Paediatric Vestibular and Balance Clinic for evaluation were included.74 children were included in this study (Mean age: 10.04 ± 3.9). We found a slight female predominance, n = 38 (51.35%). Abnormal vestibular function was observed in 60.8% of children. Vestibular migraine (VM) was the most common aetiologic cause, n = 35 (47.3%), followed by vestibular/balance delay (n = 11).The most prevalent cause of dizziness was VM, followed by vestibular delay found in children with isolated speech and language delay. We highlight the importance of awareness of various causes of dizziness in children amongst carers and physicians to diagnose and manage it early.Conclusion: Paediatric vestibular and balance services have recently gained attention across the globe. We present our one-year experience exploring the aetiology of paediatric vestibular disorders in a recently established Paediatric vestibular and balance clinic.Children and adolescents under 18 referred to the Paediatric Vestibular and Balance Clinic for evaluation were included.74 children were included in this study (Mean age: 10.04 ± 3.9). We found a slight female predominance, n = 38 (51.35%). Abnormal vestibular function was observed in 60.8% of children. Vestibular migraine (VM) was the most common aetiologic cause, n = 35 (47.3%), followed by vestibular/balance delay (n = 11).The most prevalent cause of dizziness was VM, followed by vestibular delay found in children with isolated speech and language delay. We highlight the importance of awareness of various causes of dizziness in children amongst carers and physicians to diagnose and manage it early. [ABSTRACT FROM AUTHOR]

Objectives: Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder which is also the most common cause of chronic dizziness. Effective treatment is dependent on the awareness of the provider's knowledge of PPPD and correct provision of treatment. This study was aimed to assess the awareness of PPPD and practice patterns among a diverse group of providers who care for patients with chronic dizziness in the outpatient clinics. Materials and Methods: A 12-question web-based survey was distributed to a cross-sectional convenience sample of medical providers from primary care including general practitioners, otorhinolaryngology (ORL) and internal medicine all over Malaysia. We analyzed the responses using multivariate logistic regression. Results: Of the 186 included responses, only 46.7% (85 respondents) replied they have heard of PPPD and 158 (84.9%) have actually encountered patients with symptoms describing PPPD. Those in primary care had less odds of having heard of PPPD (adjusted odds ratio [aOR] 0.37 confidence interval [CI] 0.18–0.76) nor treated patients with PPPD symptoms (aOR 0.18 CI 0.07–0.49) when compared to the General Medical and ORL providers. In terms of treatment of PPPD, gender, level of training, and practice setting predicted the provision of therapy. Conclusion: PPPD awareness is still lacking among our providers and the current practices reflect that the management of chronic dizziness is focused on ruling out systemic causes. Now is the time to invest in health communication strategies to improve the awareness and knowledge of managing chronic dizziness especially PPPD. [ABSTRACT FROM AUTHOR]

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 course. [ABSTRACT FROM AUTHOR]

Temporal lobe meningoencephalocele is a rare entity and the acquired etiology is commoner especially from iatrogenic injury to the tegmen during mastoidectomy. Non-specificity of its clinical presentations often lead to delay in diagnosis and its neurological sequalae can be devastating. Hence, both clinical suspicion and imaging are both complementary. Various approaches have been described in meningoencephalocele repair. Here, we described a successful repair of the disease via transmastoid method for a huge tegmen defect, with simple materials, included surgicel and temporalis fascia graft. [ABSTRACT FROM AUTHOR]

Introduction Parotid gland squamous cell carcinoma is an uncommon aggressive neoplasm with poor prognosis. Aural polyps are usually the presenting features of chronic suppurative otitis media, tuberculous otitis media, and adenoma or carcinoma. The malignant aural polyp is very rare. Parotid gland carcinoma masquerading as an aural polyp has rarely been described in the literature. Case Report: We report a case study of parotid squamous cell carcinoma in a 29-year-old male masquerading as an ear polyp. Conclusion: Parotid gland primary squamous cell carcinoma is a rapidly advancing neoplasm which carries poor prognosis despite multimodality treatment. Diligent clinical and histopathological evaluation is imperative to discriminate this rare aggressive disease from the metastatic and other primary cancers of the parotid. A high index of suspicion is crucial in refractory aural polyps to arrive at early diagnosis. [ABSTRACT FROM AUTHOR]

In the article, the authors discuss new-onset dysphonia as one of the silent symptoms of coronavirus disease 2019 (COVID-19). Also cited are the myriad etiologic factors linking COVID-19 and dysphonia like vocal cord injury due to forceful coughing, postviral vagal neuropathy (PVVN), and vocal cord palsy, and the study showing the effects of COVID-19 on voice quality of patients.

Abstract 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. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 47-year-old man with foreign bodies in the larynx. Three days prior to his presentation, the patient complained of throat discomfort but had no difficulty in breathing or stridor. A foreign body in the subglottic region within the glottic chink was revealed by flexible rhinolaryngoscopy. Another foreign body was found below the first one that was removed with a forceps.

Cervical rib is a congenital phenomenon that usually occurs in association with upper-limb neurovascular symptoms. The presence of a cervical rib displaces the great vessels that cross the thoracic outlet superiorly and proceed into the neck. We report an unusual case of iatrogenic hemorrhage during a tracheostomy in a patient whose right subclavian artery had been displaced by a cervical rib. Our aim is to alert surgeons to the hidden risks of this phenomenon. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder where there is persistent dizziness or unsteadiness occurring on most days for more than 3 months duration. Treatment recommendations for PPPD include vestibular rehabilitation therapy (VRT) with or without medications and/or cognitive behavioral therapy. Objectives: This paper is a pilot study designed to compare the effects of Bal Ex as a home-based VRT on the quality of life (EQ-5D), dizziness handicap (DHI) and mental health (DASS-21) against hospital-based VRT. Design: This was an assessor-blinded, randomized controlled pilot study where PPPD patients were randomly selected to undergo Bal Ex, the home-based VRT (intervention group) or hospital-based (control group) VRT. The participants were reviewed at 4 weeks and 12 weeks after the start of therapy to assess the primary endpoints using the subjective improvement in symptoms as reported by patients, changes in DHI scores, DASS-21 scores and EQ5D VAS scores. Results: Thirty PPPD patients successfully completed the study with 15 in each study group. Within 4 weeks, there were significant improvements in the total DHI scores as well as anxiety levels. By the end of 12 weeks, there were significant improvements in the DHI, DASS-21 and EQ5D. The degree of improvement between Bal Ex and the control was comparable. Conclusion: VRT is an effective modality in significantly improving quality of life, dizziness handicap, depression, and anxiety levels within 3 months in PPPD. Preliminary results show Bal Ex is as effective as hospital-based VRT and should be considered as a treatment option for PPPD. [ABSTRACT FROM AUTHOR]

We report the rare occurrence of bilateral asymmetrical mucoceles of the paranasal sinuses that resulted in a unilateral orbital complication. Th e patient was a 47-year-old woman who presented with complaints of diplopia, blurred vision, and protrusion of her right eye that had progressed over a period of several months following an upper respiratory tract infection. Computed tomography detected the presence of two large, asymmetrical mucoceles. Th e lesion on the right involved the frontal and ethmoid sinuses, and the one on the left involved the ethmoid sinus. The mucoceles were locally expansile and had eroded the surrounding bony structures on the right. The expansile nature of the right-sided mass had displaced the right orbit, which was the cause of the vision deterioration. Transnasal endoscopic surgery was performed to excise and marsupialize the mucoceles. This modality was preferred over conventional open surgery because it affords good visualization, it is safe, and it is a less morbid procedure. Th e patient’s recovery was uneventful, and she was discharged home on the third postoperative day. On continuing follow-up, her vision had improved, her intraocular pressure had returned to normal, and her orbits were in their normal position. Based on our literature search, no case of bilateral frontal and ethmoid sinus mucoceles has been previously reported. [ABSTRACT FROM AUTHOR]

The article focuses on a woman presented to an outpatient otolaryngology clinic with a 3-day history of an earache on the right caused by a dog tick found on her tympanic membrane. It says that the woman reported no discharge, tinnitus or loss of hearing. The patient was admitted to the ward for removal of the tick under general anesthesia.

This article focuses on a method of illuminating the surgical field during tonsillectomy with the aid of a flexible fiberoptic light source. A fiberoptic guide light is attached to the Boyle-Davis retractor blade with an elastic rubber band. The surgical field is always illuminated, and lighting is not dependent on the surgeon to illuminate the surgical field with his headlight. The fiberoptic light source is similar to those used for other otolaryngologic procedures, such as nasal endoscopy and laryngoscopy. It uses a cold light source.

The authors describe a novel way of fashioning an endoscope holder from a common retractor and an ear speculum. Using such a device during endoscopic sinus surgery leaves both of the surgeon's hands free to manipulate the instruments. [ABSTRACT FROM AUTHOR]

Objective To share our experience with a new delivery system for the flowable hemostatic matrix, FloSeal, in endoscopic and microscopic skull base surgery. Methods We prospectively analyzed the use of FloSeal with a hemostatic delivery system in transnasal endoscopic and microscopic skull base procedures performed at the authors' institution from January 1, 2015, to June 30, 2015. In all cases the number of aliquots was noted for the entire operation, and the total number of FloSeal ampules of 5 mL was also recorded. Results Our device allowed controlled application of small amounts (0.5–1 mL) of FloSeal to the site of bleeding. This controlled application resulted not only in increased visibility during its application, but it also reduced the amount of FloSeal required during the procedure. We were able to use 5–10 applications per 5-mL ampule of FloSeal within an individual procedure. No procedure required more than one 5-mL ampule of FloSeal. Therefore, the use of our device results in a reduction of costs. Prior to the use of our device, we were often only able to use 1 vial of 5 ml of material for 1 or 2 applications, especially in transnasal endoscopic procedures when working along a deep corridor. Conclusions Our results indicate that our delivery device of FlowSeal can effectively control hemostasis by applying small amounts of FlowSeal to the site of bleeding. This results in increased visibility during hemostasis and a reduction of cost. [ABSTRACT FROM AUTHOR]

Introduction: Atypical infratemporal fossa infections are rare and potentially fatal. Case Report: A case of an aspergillosis localized in the infratemporal fossa and another case of tuberculosis of the infratemporal fossa originating from the maxillary sinus, is described. The first patient was immunocompromised and showed symptoms of facial numbness; whereas the other was an immunocompetent man who complained of trigeminal neuralgia type pain. It was difficult to differentiate between infection and tumour despite the utilization of computed tomography scans and magnetic resonance imaging. Conclusion: These cases illustrate the need for a high index of suspicion; in addition to endoscopic confirmation and histopathology to establish precise diagnosis and early intervention. [ABSTRACT FROM AUTHOR]

We present our experience in managing pathologies involving the anterior and middle cranial base using an endoscopic transnasal approach, highlighting the surgical technique, indications, and complications. The different types of endoscopic approaches used include the transtuberculum/transplanum, transcribiform, transsellar, and cavernous sinus approaches. The common indications include repair of cerebrospinal fluid leaks (both spontaneous and post traumatic) and excision of pituitary adenomas, meningiomas, craniopharyngiomas, esthesioneuroblastomas, and other malignancies of the anterior cranial base. Careful reconstruction is performed with the multilayer technique utilizing fat, fascia lata, and fibrin sealant. The endoscopic transnasal approach, coupled with the present-day sophisticated neuronavigation systems, allows access to lesions in the midline extending from the cribriform plate to the craniovertebral junction. However, preoperative planning and careful selection of cases with evaluation of each case on an individual basis with regard to the lateral extension of the lesion are imperative. [ABSTRACT FROM AUTHOR]

Introduction: Vestibular paroxysmia (VP) is a condition with recurrent short bouts of vertigo and is thought to be part of a neurovascular compression syndrome caused by the vascular loop. However, this is still being debated as vascular loops are considered as normal variants with limited studies involving vertiginous patients. Objectives: The aim of this paper is to study the association between audiovestibular symptoms and the presence of vascular loops and to study the association between vestibular paroxysmia and vascular loops. Design: This is a retrospective analysis of clinical, audiological and MRI findings of patients with and without vascular loops and vestibular paroxysmia from 2000 to 2020. Results: A total of 470 MRI Internal Auditory Meatus scans were performed during the study period of which, 71 (15.1%) had vascular loops and 162 (34.5%) had normal MRI which were used as controls. From the 233 subjects recruited, there were 37 subjects with VP and 196 non VP subjects were used as controls. There was no association between the vascular loop and control groups in terms of co-morbidity and audiovestibular symptoms. The VP group had a significantly older mean age of 51.8 (SD ± 10.3) as compared to the non VP group with the mean age of 45.6 (SD ± 15.5). The VP group had higher number of patients presenting with hearing loss at 97.3% when compared with those without VP (80.1%) (P =.01). The odds of having a vascular loop giving rise to VP was not statistically significant at 0.82 (95% CI 0.3735-1.7989) P =.62. Conclusion: The vascular loop is a normal variant which may or may not give rise to audiovestibular symptoms or vestibular paroxysmia. Clinical assessment is still most important tool in deriving a diagnosis of VP and MRI may be useful to rule out other central causes. [ABSTRACT FROM AUTHOR]

The article discusses case studies of using an endoscopic transnasal approach in children. The patients include a 13-year-old male with Type 1 Chiari malformation, a 12-year-old male and a three-year-old boy with lower limb weakness. Topics include the limit of the use of an endoscopic transnasal technique, the use of unilateral inferior turbinectomy in all patients, and the benefits of such approach in craniofacial abnormalities.

A reply from the authors of the article "Treatment of allergic rhinitis and urticaria: a review of the newest antihistamine drug bilastine," that was published in a previous issue is presented.

Context: The Fukuda stepping test (FST) is used to assess the labyrinthine function via the vestibulospinal reflex. The test is meant to be conducted in a quiet room, but in a busy clinic setting, it is often performed in the clinic itself, and individuals are exposed to environmental sounds. Aims: The aim of this study was to assess the effects of environmental sounds and the effects of fixed directional sound on the outcome of FST. Settings and Design: This is an observational study. Subjects and Methods: Thirty healthy participants performed the FST in the otorhinolaryngology clinic, in a sound-treated room, and then in a sound-treated room with the presence of a fixed directional sound where the angle of rotation, angle of displacement, and distance of displacement were compared. Statistical Analysis Used: Independent t-test and Chi-squared test were used for statistical analysis. Results: There was no statistical difference in the angle of rotation and angle of displacement in all three settings. Although the mean distance of displacement was above 50 cm in all three settings, there was a significant reduction between clinic versus sound-treated room (P = 0.016) and clinic versus room with sound-treated directional sound (P = 0.002). Fixed directional sound had no significant influence on the direction of rotation in all the participants. Conclusions: Performing FST in the standard clinic will not affect the results. Concurrently, we suggest omitting measurement of the distance of displacement in FST as it is not reproducible in our normal sample and is highly susceptible to auditory cues but to focus on the angle of rotation. [ABSTRACT FROM AUTHOR]

We conducted a prospective study of 60 patients in a tertiary care referral center to ascertain the status of cell-mediated immunity as determined by delayed hypersensitivity reactions in patients with nasopharyngeal carcinoma (NPC) or allergic rhinitis. Delayed hypersensitivity as detected by Mantoux testing is generally accepted as a reflection of the level of cell-mediated immunoactivity--the less hypersensitivity reaction that occurs, the lower the level of immunoactivity is, and vice versa. Our study population was made up of three groups: 20 newly diagnosed patients with NPC (pretreatment), 20 age- and sex-matched patients with allergic rhinitis, and 20 matched controls without either disease. A negative Mantoux test (0- to 5-mm induration) was seen in 13 patients with NPC (65.0%), in 17 patients with allergic rhinitis (85.0%), and in 16 controls (80.0%); none of these differences was statistically significant. However, it is interesting that while the NPC group had the lowest percentage of negative Mantoux results overall, it had the highest percentage of patients who had no reaction at all (i.e., 0-mm induration); a complete absence of any reaction was seen in 7 of the 13 Mantoux-negative NPC patients (53.8%), compared with 2 of the 17 Mantoux-negative allergic rhinitis patients (11.8%) and 3 of the 16 Mantoux-negative controls (18.8%). An absence of a reaction generally indicates a very limited degree of cell-mediated immunoactivity. Therefore, we conclude that patients with NPC appear to have significantly less cell-mediated immunity than do patients with allergic rhinitis and normal controls; no statistically significant difference was noted between the latter two groups. [ABSTRACT FROM AUTHOR]

Aim: Endoscopic endonasal nasopharyngectomy (EEN) for recurrent nasopharyngeal carcinoma (rNPC) is being increasingly used due to the added high magnification, reduced morbidities associated with open procedures and good survival outcomes. Most studies looked at usage of EEN in patients with lower recurrent staging (rT1 and rT2) although more and more surgeons are studying the outcome of EEN in advanced rNPC (rT3 and rT4). The aims of this study were to report the long-term 5-year survival outcome of EEN performed in patients with advanced rNPC, and to determine any prognostic factors for patients' survival. Methods: All patients who underwent EEN for advanced rNPC between January 2003 and December 2015 inclusive were analyzed. All surgeries were performed in University Malaya Medical Centre in Kuala Lumpur and Queen Elizabeth Hospital in Sabah. We reported the 5-year overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) and any related complications and significant prognostic factors. Results: Twelve patients with rNPC (2 rT3 and 10 rT4) were followed-up over a mean duration of 44.8 months (range, 40-440 weeks). The 5-year OS was 50.0% (mean 44.75 months), DFS was 25.0% (mean 35.25 months) and the DSS was 58.3% (mean 43.33 months). No severe operative complications were encountered and no independent prognostic factors for survival outcome were identified. Conclusion: This is the first report in English that exclusively described the long-term 5-year survival data in patients with both rT3 and rT4 recurrent NPC after EEN. The data suggest that EEN is a feasible treatment to improve survival with minimal morbidities in patients with rT3 and rT4 recurrent NPC. However, more studies with larger patient size is recommended. [ABSTRACT FROM AUTHOR]

Background: Orbital cavernous hemangiomas (OCH) are the most common adult orbital tumor and represent an ideal index lesion for endonasal orbital tumor surgery. In order to standardize outcomes reporting, an anatomic‐based staging system was developed. Methods: An international, multidisciplinary panel of 23 experts in orbital tumor surgery was formed. A modified Delphi method was used to develop the cavernous hemangioma exclusively endonasal resection (CHEER) staging system with a total of 2 rounds being completed. Results: Tumors medial to a plane along the long axis of the optic nerve may be considered amenable for an exclusively endonasal resection. In select cases, tumors may extend inferolaterally if the tumor remains below a plane from the contralateral naris through the long axis of the optic nerve (ie, plane of resectability [POR]). This definition reached consensus with 91.3% of panelists in agreement. Five stages were designed based on increasing technical resection difficulty and potential for morbidity. Stages were based on the relationship of the tumor to the extraocular muscles, the inferomedial muscular trunk of the ophthalmic artery (IMT), and orbital foramina. Staging by anatomic location also reached consensus with 87.0% of panelists in agreement. Size was not included in the staging system due to the lack of agreement on the contribution of size to resection difficulty. Conclusion: Endoscopic orbital tumor surgery is a nascent field with a growing, yet heterogeneous, body of literature. The CHEER staging system is designed to facilitate international, high‐quality, standardized studies establishing the safety, efficacy, and outcomes of endonasal resection of OCH. [ABSTRACT FROM AUTHOR]

Objective: To develop a portable and affordable system for diagnosing pathological horizontal nystagmus (oscillatory rapid eye movement) in remote clinics. It is aimed to be a temporary alternative to the golden standard tool which is the Video Nystagmography which is expensive and office-based equipment. Method: The team created a system composed of a hardware gadget and software application. The modified goggle with a built-in camera and microcontroller is used to record and analyze the induced nystagmus. The analyzed data is then transmitted via Bluetooth to the user portable device which displays the results. Programming PSCN, it was tested in the outpatient clinic. During the clinical evaluation of the gadget, the nystagmus was induced and recorded by the Video Nystagmography. Immediately, we repeated the experiment using the created system. Eventually, the two results were compared to set up the thresholds in the new system. After calibration, the amended algorithm of PSCN tested another ten recorded nystagmus videos to evaluate its accuracy. Results: The portable system showed high clinical reliability during the testing in comparison to golden standard Videonystagmography. In the second stage, it showed an accuracy ratio up to 80% during testing the ten recorded videos. It also managed to differntiate the real nystagmus from the artifacts. Conclusion: This trial proofed the concept of portable system as an assistive diagnostic tool for pathological nystagmus. However, a more clinical trial is required to establish it as a portable alternative for the golden standard. [ABSTRACT FROM AUTHOR]

Endoscopic endonasal nasopharyngectomy (EEN) has become increasingly used for recurrent nasopharyngeal carcinoma (rNPC) due to reduced functional and cosmetic morbidities compared to conventional external approach. Majority of the existing studies on EEN focused on patients with lower recurrent staging of rT1 and rT2. The aims of this study were to provide a preliminary report on the outcome of EEN performed in patients with advanced (rT3 and rT4) rNPC, and to determine the prognostic factors for patients' survival. All patients who underwent EEN for rNPC between January 2003 and December 2015 inclusive were analyzed. All surgeries were performed in University Malaya Medical Centre in Kuala Lumpur and Queen Elizabeth Hospital in Sabah, by a single surgeon. We reported the 2-year overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) and any related complications and significant prognostic factors. Fifteen patients with recurrent NPC (2 rT3 and 13 rT4 tumours) underwent EEN over the 13 years period. The mean age was 50.4 years (range 30-65) and the mean follow-up period was 28.7 months (range 9-81 weeks). The 2-year OS, DFS and DSS were 66.7 % (mean 19.4 months), 40 % (mean 15.7 months) and 73.3 % (mean 20.2 months), respectively. No severe operative complications were encountered. No independent prognostic factors for survival outcome were identified. This is the first preliminary report in English that exclusively looked at the use of EEN in advanced rT3 and rT4 NPCs, showing favourable patient outcome. However, further long-term follow-up of patients is required. [ABSTRACT FROM AUTHOR]

Allergic rhinitis and urticaria are common allergic diseases that may have a major negative impact on patients' quality of life. Bilastine, a novel new-generation antihistamine that is highly selective for the H1 histamine receptor, has a rapid onset and prolonged duration of action. This agent does not interact with the cytochrome P450 system and does not undergo significant metabolism in humans, suggesting that it has very low potential for drug-drug interactions, and does not require dose adjustment in renal impairment. As bilastine is not metabolized and is excreted largely unchanged, hepatic impairment is not expected to increase systemic exposure above the drug's safety margin. Bilastine has demonstrated similar efficacy to cetirizine and desloratadine in patients with seasonal allergic rhinitis and, in a Vienna Chamber study, a potentially longer duration of action than fexofenadine in patients with asymptomatic seasonal allergic rhinitis. It has also shown significant efficacy (similar to that of cetirizine) and safety in the long-term treatment of perennial allergic rhinitis. Bilastine showed similar efficacy to levocetirizine in patients with chronic spontaneous urticaria and can be safely used at doses of up to fourfold higher than standard dosage (80 mg once daily). The fourfold higher than standard dose is specified as an acceptable second-line treatment option for urticaria in international guidelines. Bilastine is generally well tolerated, both at standard and at supratherapeutic doses, appears to have less sedative potential than other second-generation antihistamines, and has no cardiotoxicity. Based on its pharmacokinetic properties, efficacy, and tolerability profile, bilastine will be valuable in the management of allergic rhinitis and urticaria. [ABSTRACT FROM AUTHOR]

Purpose: Osteoradionecrosis (ORN) is a rare yet well-recognized complication following radiotherapy to the head and neck. We illustrate the only case of a spontaneous extrusion of the sequestered C1 arch through the oral cavity and discuss our experience with a combined endoscopic transnasal and transoral approach for cervical ORN.Methods: A 56-year-old female presented with a 3-month history of blood-stained nasal discharge. She had been treated with radiotherapy for nasopharyngeal carcinoma 25 years earlier. Flexible nasal endoscopy demonstrated an exposed bone with an edematous posterior nasopharyngeal mass. Computed tomography showed a pre-vertebral mass with destruction of C1 and C2. She underwent occipito-cervical fusion followed by a combined transnasal and transoral endoscopic debridement of non-viable bone in the same perioperative setting. Healing of the raw mucosa was by secondary intention and reconstruction was not performed.Results: Histopathological examination reported ulcerated inflamed granulation tissue with no evidence of malignancy. During follow-up, she remained neurologically intact with no recurrence.Conclusion: Using both nasal and oral spaces allows placement of the endoscope in the nasal cavity and surgical instruments in the oral cavity without splitting the palate. Hence, the endoscopic transnasal and transoral approach has vast potential to be effective in carefully selected cases of cervical ORN. [ABSTRACT FROM AUTHOR]

Objectives: This study includes the direct sequencing of cornulin (CRNN) gene to elucidate the possible mechanism of CRNN downregulation and explore the genetic imbalances at 1q21.3 across oral squamous cell carcinoma (OSCC) samples. Materials and methods: In mutation screening of CRNN gene, gDNA from OSCC tissues were extracted, amplified, and followed by direct sequencing. OSCC samples were also subjected to fragment analysis on CRNN gene to investigate its microsatellite instability (MSI) and loss of heterozygosity (LOH). Immunohistochemistry was performed to validate CRNN downregulation in OSCC samples. Results: No pathogenic mutation was found in CRNN gene, while high frequency of allelic imbalances was found at 1q21.3 region. MSI was found more frequent (25.3 %) than LOH (9.3 %). Approximately 22.6 % of cases had high MSI which reflects higher probability of inactivation of DNA mismatch repair genes. MSI showed significant association with no betel quid chewing ( p = 0.003) and tongue subsite ( p = 0.026). LOH was associated with ethnicity ( p = 0.008) and advanced staging ( p = 0.039). The LOH at 1q21.3 was identified to be as an independent prognostic marker in OSCC (HRR = 7.15 (95 % CI, 1.41-36.25), p = 0.018). Downregulation of CRNN was found among MSI-positive OSCCs and was associated with poor prognosis ( p = 0.044). Conclusion: This study showed a significant correlation between LOH/MSI at 1q21.3 with clinical outcomes and that downregulation of CRNN gene could be considered as a prognostic marker of OSCC. Clinical relevance: Insights of the downregulation mode of CRNN gene lays the basis of drug development on this gene as well as revealing its prognostic value. [ABSTRACT FROM AUTHOR]

Purpose: This paper reports an unusual case of a transsphenoidal encephalocele and discusses our experience with a minimally invasive management. To the best of our knowledge, we present the first case of a combined endoscopic transnasal and transoral approach to a transsphenoidal encephalocele in an infant. Methods: A 17-day-old boy, who was referred for further assessment of upper airway obstruction, presented with respiratory distress and feeding difficulties. Bronchoscopy and imaging revealed a transsphenoidal encephalocele. At the age of 48 days, he underwent a combined endoscopic transnasal and transoral excision of the nasal component of the encephalocele. This approach, with the aid of neuronavigation, allows good demarcation of the extra-cranial neck of the transsphenoidal encephalocele. We were able to cauterize and carefully dissect the sac prior to excision. The defect of the neck was clearly visualized, and Valsalva manoeuvre was performed to exclude any CSF leak. As the defect was small, it was allowed to heal by secondary intention. Results: The patient's recovery was uneventful, and he tolerated full feeds orally on day 2. Postoperative imaging demonstrated no evidence of recurrence of the nasal encephalocele. Endoscopic follow-up showed good healing of the mucosa and no cerebrospinal fluid leak. Conclusions: The surgical management of transsphenoidal encephalocele in neonates and infants is challenging. We describe a safe technique with low morbidity in managing such a condition. The combined endoscopic transnasal and transoral approach with neuronavigation is a minimally invasive, safe and feasible alternative, even for children below 1 year of age. [ABSTRACT FROM AUTHOR]

Basaloid squamous cell carcinoma (BSCC) is a rare subtype of squamous cell carcinoma. To date, only 95 cases of sinonasal BSCC have been reported in the English-language literature, and they account for 5% of all cases of head and neck BSCC. We describe what we believe is only the second reported case of a sinonasal tract BSCC that metastasized to the liver. The patient was a 36-year-old woman who presented with right-sided nasal obstruction and a foul-smelling discharge. Clinical examination and imaging identified a large lobulated enhancing mass in the right nasal cavity. Following excision of the mass, the patient was scheduled for radiotherapy. However, before it could be administered, follow-up imaging detected a metastasis to the liver and lung, and the patient was switched to chemotherapy. Initially, she responded well clinically, but at 5 months postoperatively, a follow-up CT showed an increasing metastatic presence in the liver and bone. The patient died of her disease 1 year after surgery. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

This study aims to assess the association between microbial composition, biofilm formation and chronic otorhinolaryngologic disorders in Malaysia. A total of 45 patients with chronic rhinosinusitis, chronic tonsillitis and chronic suppurative otitis media and 15 asymptomatic control patients were studied. Swab samples were obtained from these subjects. Samples were studied by conventional microbiological culturing, PCR-based microbial detection and Confocal Laser Scanning Microscopy (CLSM). Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae, coagulase-negative staphylococci (CoNS) and other Streptococcus species were detected in subjects of both patient and control groups. Biofilm was observed in approximately half of the smear prepared from swab samples obtained from subjects of the patient group. Most of these were polymicrobial biofilms. S. aureus biofilm was most prevalent among nasal samples while H. influenzae biofilm was more common among ear and throat samples. Results from this study supported the hypothesis that chronic otorhinolaryngologic diseases may be biofilm related. Due to the presence of unculturable bacteria in biofilms present in specimens from ear, nose and throat, the use of molecular methods in combination with conventional microbiological culturing has demonstrated an improvement in the detection of bacteria from such specimens in this study. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications. [ABSTRACT FROM AUTHOR]

Despite the advances in diagnosis and treatment of oral squamous cell carcinoma (OSCC), mortality and morbidity rates have not improved over the past decade. A major drawback in diagnosis and treatment of OSCC is the lack of knowledge relating to how genetic instability in oral cancer genomes affects oral carcinogenesis. Hence, the key aim of this study was to identify copy number alterations (CNAs) that may be cancer associated in OSCC using high-resolution array comparative genomic hybridization (aCGH). To our knowledge this is the first study to use ultra-high density aCGH microarrays to profile a large number of OSCC genomes (n = 46). The most frequently amplified CNAs were located on chromosome 11q11(52%), 2p22.3(52%), 1q21.3–q22(54%), 6p21.32(59%), 20p13(61%), 7q34(52% and 72%),8p11.23–p11.22(80%), 8q11.1–q24.4(54%), 9q13–q34.3(54%), 11q23.3–q25(57%); 14q21.3–q31.1(54%); 14q31.3–q32.33(57%), 20p13–p12.3(54%) and 20q11.21–q13.33(52%). The most frequently deleted chromosome region was located on 3q26.1 (54%). In order to verify the CNAs from aCGH using quantitative polymerase chain reaction (qPCR), the three top most amplified regions and their associated genes, namely ADAM5P (8p11.23–p11.22), MGAM (7q34) and SIRPB1 (20p13.1), were selected in this study. The ADAM5P locus was found to be amplified in 39 samples and deleted in one; MGAM (24 amplifications and 3 deletions); and SIRPB1 (12 amplifications, others undetermined). On the basis of putative cancer-related annotations, two genes, namely ADAM metallopeptidase domain 9 (ADAM9) and maltase-glucoamylase alpha-glucosidase (MGAM), that mapped to CNA regions were selected for further evaluation of their mRNA expression using reverse transcriptase qPCR. The over-expression of MGAM was confirmed with a 6.6 fold increase in expression at the mRNA level whereas the fold change in ADAM9 demonstrated a 1.6 fold increase. This study has identified significant regions in the OSCC genome that were amplified and resulted in consequent over-expression of the MGAM and ADAM9 genes that may be utilized as biological markers for OSCC. [ABSTRACT FROM AUTHOR]