Challenges in Managing Intractable Epistaxis in a Post-nasal Surgery and Radiated Cancer Patient: A Case Report and Literature Review

Recurrent epistaxis represents an alarming sign that may suggest a sinister aetiology, especially in patients with previous head and neck malignancy. The recognition of certain potentially life-threatening conditions, namely pseudoaneurysm or tumour recurrence, remains prudence to avoid disastrous repercussion. Nasal endoscopy has become an essential tool in otolaryngology. It can aid identify the underlying cause of epistasis and facilitate therapeutic management. On the other hand, radio imaging is highly sensitive in detecting vascular lesions, besides providing a pre-operative mapping if surgical intervention is planned. This paper reported a patient with sphenoidal sinus squamous cell carcinoma in remission presented with torrential epistaxis not relieved with nasal packing. Despite a repeated angiogram and magnetic resonance image, the identification of the source of bleeding remained futile, culminating in an examination under general anaesthesia. The diagnosis of carotid blowout syndrome was made intraoperatively, and the bleeding was temporarily secured with a muscular patch, preceded by the insertion of a vascular stent. The authors wish to highlight the importance of examination under general anaesthesia if radio imaging does not correlate to the clinical findings. Management options for carotid blowout should be tailored to the patients' medical conditions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03625-4.

Temporal bone squamous cell carcinoma: A change in treatment

Temporal bone squamous cell carcinoma (TBSCC) is a rare head and neck malignancy with the incidence 0.8 -1.0 cases in 1 million population. We are reporting a case series on the TBSCC cases that were operated on at Sarawak General Hospital, Malaysia. Ten patients were identified and collected with the presentation and type of surgery performed. It has been challenging for us to manage with recorded 2 years surviving in 6 out of 10 patients operated within this period. An adequate management with proper surgical resection of tumour and radiotherapy can extend the life expectancy for TBSCC patients.

Dilemma in management of cervico-facial cystic hygroma

Cervico facial cystic hygroma and tongue lymphagioma is rare representative of spectrum of lymphatic malformations. Conservative management with sclerosants alone has proven to be successful. However, sudden enlargement of these cervico facial lymphangiomas leads to catastrophic airway obstruction leading to debility in feeding and speech. Therefore, surgery is indicated in such case to prevent such a catastrophic problem. We report here the case of a 3-yearold boy with cervico facial hygroma involving the tongue. We successfully treated him with a combination of surgery and OK432 injection.

A new experience of auditory brainstem implantation in Malaysia

Auditory brainstem implantation (ABI) is the only solution to restore hearing when cochlear nerves are disrupted together with the pathologies where bilateral cochleae do not provide a suitable location for cochlear implantation. We reported first two successful auditory brainstem implantation cases in patients with neurofibromatosis Type II (NF2) with bilateral acoustic neuroma causing bilateral profound sensorineural hearing loss in Malaysia. A good candidate selection, dedicated surgeons and rehabilitation team as well as strong family support are the crucial factors in achieving the best possible surgical, audiological and speech outcomes.

A review of surgical and audiological outcomes of bonebridge at tertiary centres in Malaysia

OBJECTIVES

To investigate the surgical and audiological outcome of Bonebridge (BB) at tertiary centres in Malaysia.

STUDY DESIGN

Prospective, intra-subject repeated measurements of which each subject is his/her own control, from year 2012 to 2016 at two tertiary referral centres.

METHODS

Twenty patients with hearing loss who fulfilled criteria for BB and showed good response to bone conduction hearing aid trial were included. Implantations of BB were carried out under general anaesthesia with preoperative computed tomography (CT) planning. Complications were monitored up to six months postoperatively. Subjects' audiometric thresholds for air conduction, bone conduction and sound field at frequencies of 250Hz to 8kHz were assessed preoperatively and at six months postoperatively. Subjects' satisfaction was evaluated at 6 months post operatively with Hearing Device Satisfaction Scale (HDSS) questionnaire.

RESULTS

There was no major complication reported. Mean aided sound field thresholds showed significant improvement for more than 30dB from 500 to 4000kHz (p<0.05). There was no significant change in mean unaided air conduction and bone conduction thresholds pre and post operatively from 500 to 4000kHz, with a difference of less than 5dB (p>0.05). All the patients were very satisfied (>80%) with the implant, attributing to the promising functional outcome and acceptable cosmetic appearance.

CONCLUSIONS

BB implantation surgery is safe and is effective in restoring hearing deficits among patients aged five and above with conductive or mixed hearing loss and single-sided hearing loss.

Pilot study comparing steroid-impregnated and non-steroid-impregnated absorbable nasal dressing following endoscopic sinus surgery

INTRODUCTION

Endoscopic sinus surgery (ESS) is the mainstay for treatment of chronic rhinosinusitis versus maximal medical therapy. We propose a more economical option, by using steroid-impregnated Gelfoam instead of Nasopore post ESS, as it is less expensive and has showed effectiveness in preventing post-operative bleeding.

MATERIALS AND METHODS

A randomised, double-blinded, placebo-controlled trial was carried out in eight patients with chronic rhinosinusitis or nasal polyposis who were planned for bilateral endoscopic sinus surgery. A Peri-operative Sinus Endoscopy (POSE) Score and Lund-Kennedy Endoscopic Score (LKES) were recorded. The use of hydrocortisone-impregnated Gelfoam dressing versus normal saline-impregnated Gelfoam dressing were compared. Scores were repeated post-operatively at one week, three weeks and three months interval.

RESULTS

For LKES, at the end of three months, 50% of the patients had the same score difference, 37.5% had better results on the study side while 12.5% had better results on the control side. Meanwhile, for POSE Score, at the end of three months, 75% of the patients had better score difference on the study side while 12.5% had better results on the control side.

CONCLUSION

Gelfoam can be used as nasal packing material to deliver topical steroid after endoscopic sinus surgery. Steroid-impregnated nasal dressing after endoscopic sinus surgery may not provide better long-term outcome.

Sinonasal angioleiomyoma

BACKGROUND

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.

Kimura's Disease: Diagnostic Challenge and Treatment Modalities

CASE REPORT

Five cases of Kimura's disease had been treated in our centre from year 2003 to 2010. All cases were presented with head and neck mass with cervical lymphadenopathy. Surgical excision was performed for all cases. Definite diagnosis was made by histopathological examination of the resected specimens. One out of five cases developed tumour recurrence four years after resection.

CONCLUSION

Surgical excision is our choice of treatment because the outcome is immediate and definite tissue diagnosis is feasible after resection. Oral corticosteroid could be considered as an option in advanced disease. However, tumour recurrence is common after cessation of steroid therapy.

Optimal Size AMBU® Laryngeal Mask Airway Among Asian Adult Population

AIM

This was a randomized single blinded study to determine optimal size for Ambu®LMA (ALMA) among Malaysian adult population.

METHODS

One hundred and twenty six non-paralyzed anaesthetized adult patients were block randomized into size 3, 4 and 5 Ambu®LMA. Optimal size is defined primarily by oropharyngeal pressure (OLP). Pharyngeal injury and ease of insertion are also taken into consideration.

RESULTS

Mean OLP was significantly higher for Size 4 and 5 compared to size 3 (p<0.001) but similar between size 4 and 5. Number of insertion attempts and insertion time were similar between sizes. Size 5 required more manipulations during insertion (p<0.005) and had higher pharyngeal injury (p=0.001) compared to size 3 and 4.

DISCUSSION

We recommend size 4 ALMA as the optimal size for Malaysian adults in view of the higher OLP compared to size 3, yet less pharyngeal injury than size 5 in spontaneously breathing patients.

Primary lacrimal sac lymphoma with recurrence: a case report

Primary lacrimal sac lymphoma is rare. The common clinical features are epiphora and medial canthal swelling which mimic nasolacrimal duct obstruction. Histological examination is therefore important to avoid delay in diagnosis and treatment. We report a case of primary lacrimal sac lymphoma in a 72-year-old female who developed a metachronous tumour at the hard palate one year after excision of the lacrimal sac tumour.

Antibiotic sensitivity and spectrum of bacterial isolates in otorhinolaryngological infection: a retrospective study

OBJECTIVES

To identify the common bacteria of otorhinolaryngological (ORL) infection in three general hospitals in the state of Sarawak, East Malaysia and to determine the antibiotic sensitivity of the common bacteria to update local antibiotic policy.

METHODS

All specimens with positive monoclonal culture, received from inpatient and outpatient Otorhinolaryngology Department in the year 2009 and 2010 were included in the study. Patients' demographics, nature of specimens, bacterial isolates and antibiotic sensitivity were analysed by using the Statistical Package for the Social Sciences (SPSS).

RESULTS

A total 244 positive monoclonal cultures were identified. Staphylococcus species and Gram negative bacilli were the commonest bacteria of ORL infections. Common ORL bacteria remain sensitive to our front line antibiotics. There are a number of multi-drug resistant isolates of MRSA, ESBL Klebsiella pneumoniae and Acinetobacter baumanii in the hospital-acquired infections.

CONCLUSION

Although resistance to antimicrobial agents is growing worldwide, first line antibiotics still show significant therapeutic advantage in our local setting. The low resistance of bacterial isolates in our community reflects judicious use of antibiotics in our routine clinical practices.

Vibrant soundbridge: a new implantable alternative to conventional hearing AIDS in children

The Vibrant Soundbridge is a new middle ear implantable hearing device. It was first introduced for adult patients with moderate to severe sensorineural hearing loss. With the innovation of the surgical techniques, its usage had been broadened for children and those patients with conductive and mixed hearing loss. We report first two cases of monoaural Vibrant Soundbridge implantation in Malaysia. They were children with bilateral conductive hearing loss who had failed to benefit from previous hearing aids. Floating mass transducers were attached in oval window and long process of incus respectively. Remarkable hearing yield was observed without surgical complication.

An unusual entry site of an intraorbital foreign body in a child

Intraorbital foreign bodies (IOrbFB) are associated with both sight and life threatening injuries. We report a case of an IOrbFB associated with retrobulbar hemorrhage and injury of the frontal sinus in an 11 year-old boy, after history of fall from the tree. Imaging studies revealed a metallic foreign body (FB) in the orbit and fracture of the walls of the frontal sinus. The usual entry route of an IOrbFB is either through the eye or orbital walls and extremely rare through the paranasal sinuses. This is the first reported case of a FB entering the orbit through the frontal sinus.

Head and neck cancer: possible causes for delay in diagnosis and treatment

OBJECTIVE

To explore the possible causes for delay in diagnosis and treatment of head and neck cancer at Sarawak General Hospital (SGH).

STUDY DESIGN

This is a prospective study of time interval between onset of symptom, first medical consultation, first specialist clinic consultation, diagnosis and treatment of head and neck cancer in otorhinolaryngology head and neck (ORL-HNS) and dental clinics at Sarawak General Hospital. Forty-two consecutive cases diagnosed to have cancer between July to December 2006 were studied.

RESULTS

Mean interval between onset of symptom and medical consultation was 3.8 months, mean interval between first medical consultation to ORL-HNS or dental clinic referral was 8.4 weeks, mean duration between first ORL-HNS or dental specialist consultation to histopathological diagnosis was 18.8 days while duration between diagnosis to definite treatment was 26.9 days.

CONCLUSION

Most cases were diagnosed at advanced stage. Patient delay was the main problem. There was significant delay by frontier health workers in identifying sinister symptoms of malignancy. Timing for diagnosis and treatment after specialist referral were comparable with other published studies.

A recurrent nasopharyngeal carcinoma with lacrimal sac involvement: a case report

We report a very rare case of recurrent nasopharyngeal carcinoma with local involvement of lacrimal sac. The patient was treated with chemotherapy and there was no recurrence noted after 1 year of follow-up.

Aneurysmal bone cyst of the maxilla

An aneurysmal bone cyst is a rare bone lesion. Its origin and precise nature remain unknown. It is seen as a locally-destructive, rapidly expandable, benign multicystic mass. We report a 17-year-old boy with an aneurysmal bone cyst of the maxilla, with extensive local involvement and bony destruction that was treated surgically. There was no recurrence noted after four years of follow-up.

Outcome of patients presenting with idiopathic facial nerve paralysis (Bell's palsy) in a tertiary centre--a five year experience

This is a retrospective study. The objective of this study is to review the factors influencing the outcome of treatment for the patients presented with idiopathic facial nerve paralysis. The demographic data, clinical presentation and management of 84 patients with idiopathic facial nerve paralysis (Bell's palsy) were collected from the medical record office, reviewed and analyzed from 2000 to 2005. Thirty-four (72.3%) out of 47 patients who were treated with oral prednisolone alone, fully recovered from Bell's palsy meanwhile 36 (97%) out of 37 patients who were treated with combination of oral prednisolone and acyclovir fully recovered. The difference was statistically significant. 42 (93.3%) out of 45 patients who presented within three days to our clinic, fully recovered while 28 (71.8%) out of 39 patients presented later then three days had full recovery from Bell's palsy. The difference was statistically significant. The outcome of full recovery is better with the patients treated with combined acyclovir and prednisolone compared with prednisolone alone. The patients who were treated after three days of clinical presentation, who were more than 50 years of age, who had concurrent chronic medical illness and facial nerve paralysis HB Grade IV to VI during initial presentation have reduced chance of full recovery of facial nerve paralysis.

A review of parotid tumours and their management: a ten-year-experience

To review the demographics, management and outcome of patients undergoing parotidectomy at a tertiary center. A total of 76 patients who underwent parotidectomies from January 1996 to December 2005 at the ORL department of our center were reviewed. All clinical, operative, postoperative, histology data were gathered and reviewed. Fine-needle aspiration cytology (FNAC) was diagnostic in 90% of patients with a sensitivity of 76% and specificity of 96%. Twenty-one patients had malignant tumours and the rest had benign or inflammatory lesions. There were a total of 48 superficial and 28 total parotidectomies performed. Facial nerve palsy occurred in 30 (39%) patients with 4% permanent palsy and 35% temporary palsy. The recurrence rate of pleomorphic adenoma was 2.6%. FNAC and CT scan were performed prior to the surgery were useful guidance in planning the operation but clinical judgment is more important. The most common surgery performed was superficial parotidectomy and the most common cause was due to pleomorphic adenoma. The incidence of complications and recurrence of tumour are comparable to other international studies. Prior knowledge of anatomy and careful planning is needed to decrease the incidence of facial nerve palsy.

Juvenile nasopharyngeal angiofibroma in a tertiary centre: ten-year experience

INTRODUCTION

This is a retrospective study that aimed to examine the outcomes of patients presenting with juvenile nasopharyngeal angiofibroma (JNA) at a tertiary centre in Malaysia.

METHODS

The demographical data, clinical presentation, investigations as well as treatment of 13 JNA patients were reviewed and collected from the medical record office at our centre from 1995 to 2005.

RESULTS

All JNA patients were male and the average age at diagnosis was 17 (range 14-28) years. They presented with recurrent painless spontaneous epistaxis, nasal obstruction, nasal discharge, a reduced sense of smell, snoring, headache and facial swelling. One patient was at stage I, eight were at stage II, three at stage III and one patient was at stage IV, based on the Fisch classification. Angiography showed that nine tumours were supplied by both internal maxillary arteries of the external carotid system, and only four tumours received blood supply from the ipsilateral internal maxillary artery. All 13 patients underwent primary surgical resection. The overall recurrence rate was 38.5 percent for the first procedure and 60 percent for the second procedure. No major complications occurred in this group of patients as a consequence of treatment, neither for the primary tumours nor for the recurrences.

CONCLUSION

JNA is a rare vascular benign tumour with highly exclusive persistence and recurrence, and typically affects adolescent boys. The management of JNA presents a challenge to ENT surgeons. Preoperative angiography and embolisation minimise intraoperative blood loss and the current shift in the treatment to endoscopic excision in selected lesions reduces perioperative morbidity.

Endoscopic orbital decompression for optic neuropathy in thyroid ophthalmopathy

Optic neuropathy, an uncommon manifestation occurs in 5% of patients with Graves' ophthalmopathy. Its outcome is good if early and proper treatment given. We reported a 49 years old male patient of Graves' disease with bilateral optic neuropathy. He underwent bilateral transnasal endoscopic orbital decompression with marked improvement of visual acuity bilaterally. The preoperative visual acuity was 6/36 in his right eye and 6/60 in his left eye. Two days after operation, his visual acuity was 6/12 in his right eye and 6/24 in his left eye. Transnasal endoscopic orbital decompression is a choice of treatment in optic neuropathy in thyroid ophthalmopathy after trial of corticosteroids.

Foreign body in the middle ear, a hearing aid complication

A 12-year-old boy with moderate to severe bilateral mixed hearing loss was planned for hearing aid placement. During the process of making ear mould impression, the impression material accidentally entered the right middle ear. Removal of the ear mould impression was possible permeatally under general anaesthesia.

Fracture synthetic tracheostomy tube: an ENT emergency

A synthetic tracheostomy tube [non-metallic type] fracturing within three days of insertion is very rare but it could lead to serious complications such as acute asphyxia or sudden death. We report three such cases at our centre. Recommendations are made to closely observe patients on tracheostomy tube in the first seven days post-insertion of the tube.

Endoscopic orbital decompression for Graves' ophthalmopathy

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.

Extensive benign sinonasal squamous papilloma

We reported a patient with an extensive benign sinonasal squamous papilloma in the right nasal cavity with involvement of right sphenoid, ethmoid, maxillary sinuses and intracranial extension. This tumour is rare with very few reported cases in the literature of such extensive in nature. The tumour is excised completely with combined endoscopic transnasal and transcranial approaches. The patient remains disease free at a year interval of follow-up.

Outcome of patients presenting with preauricular sinus in a tertiary centre--a five year experience

We reviewed the recurrence rate and possible factors influencing recurrence of preauricular sinus after excision. Seventy-one patients with 73 preauricular sinuses seen at our centre from year 2000 to 2005 were reviewed in this study. The overall recurrence rate was 14.1%. Twelve sinuses needed to be drained for an abscess prior to a definitive surgery. Different modalities used in demonstrating the sinus tract between methylene blue alone and probing together with methylene blue, showed different outcomes, which were statistically significant with a p value of < 0.05(chi-square test). A preauricular sinus with a previous history of infection or actively infected during the definitive surgery may have a higher tendency of recurrence. Meanwhile demonstrating the sinus tract by probing with lacrimal probe/sinus probe followed by injection of methylene blue reduces the recurrence rate (p < 0.05 with chi-square test).