A Foreign Body Aspiration Leading to Pneumothorax: A Case of Airway Emergency

Foreign body (FB) aspiration is a matter that should not be taken lightly. The presence of a foreign object might lead to hazardous complications, particularly in the pediatric population. These complications depend on the type and location of the aspirated object as the tracheobronchial tree has a very small diameter, and foreign bodies become stuck in the upper airways of children, causing stridor and sudden difficulty in breathing. Impaction of a foreign body in the right bronchial tree is more frequent due to the relatively straighter alignment of the right mainstem of the trachea, as opposed to the left side. Herein, we present a 10-year-old Malay boy who accidentally aspirated a pencil cap. An urgent computed tomography (CT) of the thorax revealed a suspicious intraluminal FB in the bronchus leading to pneumothorax and pneumomediastinum. He underwent a right bronchoscopy and a successful FB removal.

Concurrent Anaplastic and Papillary Thyroid Carcinoma Manifesting as a Thyrocutaneous Fistula

Anaplastic thyroid carcinoma (ATC) is a highly aggressive form of thyroid cancer with poor prognosis. Differentiated thyroid carcinoma (DTC) including papillary thyroid carcinoma (PTC) is more common and known to have a favorable outcome after treatment. Here, we report a case of a 59-year-old lady with a long-standing goiter presenting with a discharging anterior neck mass. Fine-needle aspiration cytology (FTAC) of the mass resulted with malignant cells. She underwent surgery, and histopathological examination revealed both ATC and PTC features. Mutation analysis was also performed, and results were positive for BRAF 600VE mutation. She received radiotherapy and also chemotherapy post-surgery. Treatment was well tolerated. The relatively favorable survival of this patient may suggest that synchronous ATC and DTC may have better prognosis than ATC alone. The objective of this article is to report the unique clinical presentation and favorable prognosis with combined treatment modalities.

A Red Flag: A Case of Oropharyngeal Cancer Masquerading as an Ulcer of an Infective Origin

Oropharyngeal squamous cell carcinoma is a prevalent neoplastic condition. The incidence rate in Malaysia is rising, with human papillomavirus (HPV) infection being recognized as a significant contributing factor. Hence, it is paramount for physicians to effectively diagnose and identify significant indicators that may indicate a malignant etiology. In this study, we present a case of a middle-aged Malay male who presented with the primary symptom of persistent right throat discomfort for one month. The preliminary presentation, blood parameters, and initial histopathological examination (HPE) findings indicate the presence of an infection. However, despite undergoing several medical treatments, the patient's symptoms remain, albeit with only minor clinical improvement. Subsequently, the patient underwent a biopsy under general anesthesia, which subsequently yielded a report indicating the presence of oropharyngeal squamous cell carcinoma with a negative p16 status. Therefore, it is imperative for clinicians to possess knowledge of warning flags and exercise vigilance when encountering a patient who fails to respond despite thorough and precise evaluation. If there is a strong suspicion of malignancy, it is imperative to do a comprehensive clinical investigation and regular monitoring.

Silent Killer in the Nose: Two Cases of Nasal Alveolar Rhabdomyosarcoma in Adults

We report two cases of nasal alveolar rhabdomyosarcoma (ARMS) in adult patients from our center who presented with local mass effect and systemic involvement. Our first patient had spontaneous unilateral epistaxis. Her blood investigation showed severe thrombocytopenia, and the bone marrow biopsy result showed bone marrow infiltration by non-hematopoietic malignant cells. Nasal endoscopy showed a mass arising medial to the left middle turbinate. Our second patient presented with right eye proptosis, associated with blurring of vision. Nasal endoscopy showed a right whitish nasal mass arising lateral to the middle turbinate. Both patients were diagnosed by immunohistochemical analysis showing ARMS, a soft tissue malignancy uncommon in adults. RMS in adults has a worse prognosis. Hence, the management is challenging. Early diagnostic workup is essential for the commencement of early treatment for better oncological outcomes.

Findings from a Malaysian multicentre study on oropharyngeal squamous cell carcinoma

BACKGROUND

In addition to the conventional aetiologic agents of oropharyngeal squamous cell carcinoma (OPSCC) such as tobacco usage, alcohol consumption and betel quid usage, it has been established that a proportion of OPSCC are driven by persistent oncogenic human papillomavirus (HPV) infections. Currently, there is a lack of data on the burden of HPV- associated OPSCC in Asian countries including Malaysia.

METHODS

A cross-sectional multicentre study with tissue analysis of Malaysian patients diagnosed with primary OPSCC within a five-year period, from 2015 to 2019 between 01/01/2015 to 31/12/2019 was undertaken. Determination of HPV status was carried out using p16INK4a immunohistochemistry on tissue microarrays constructed from archived formalin-fixed paraffin-embedded tissue.

RESULTS

From the cases identified, 184 cases had sufficient tissue material for analysis. Overall, median age at diagnosis was 63.0 years (IQR = 15) and 76.1% of patients were males. In our cohort, 35.3% of patients were Indian, 34.2% were Chinese, 21.2% were Malay and 9.2% were from other ethnicities. The estimated prevalence of HPV-associated OPSCC in our cohort was 31.0% (CI 24.4-38.2%). The median age for the HPV-associated OPSCC sub-group of patients was not significantly lower than the median age of patients with HPV-independent OPSCC. More than half of HPV-associated OPSCC was seen in patients of Chinese ethnicity (54.4%). Patients with HPV-associated OPSCC had a much better overall survival than patients with HPV-independent OPSCC (Log rank test; p < 0.001). Patients with HPV-associated OPSCC with no habit-related risk factors such as smoking, were found to have much better overall survival when compared to all other sub-groups.

CONCLUSIONS

The findings from our study suggests that prevalence of HPV-associated OPSCC in Malaysia, though not as high as some developed countries, is however on an upward trend. HPV-associated OPSCC appears to be more frequently encountered in patients of Chinese ethnicity. Conventional risk-factors associated with OPSCC such as smoking, alcohol consumption and betel quid chewing should still be considered when estimating prognosis of patients with HPV-associated OPSCC.

Primary Nasal Tuberculosis Masquerading as Granulomatosis With Polyangiitis: A Case Report of Diagnostic Dilemma

Primary nasal tuberculosis (TB) is a rare disease even in areas with high TB burden, possibly attributed to the protective mechanism of sinonasal mucosa. Its symptoms are subtle and can be mistaken for other granulomatous inflammatory conditions. We would like to report a case of a 70-year-old Indian lady who underwent a successful left endoscopic dacryocystorhinostomy three years ago and presented with recurrent left epiphora. During nasal endoscopy, multiple ulcerative masses with crusting were detected over the left nasal vestibule, anterior nasal septum, left inferior, and middle turbinate. Biopsy of the nasal mass revealed granulomatous inflammation without caseating necrosis. Initially, all TB-related tests were negative. As the patient had granulomatous nasal lesions with microscopic haematuria, granulomatosis with polyangiitis (GPA) was suspected. Regrettably, the patient did not respond to treatment. A repeated tissue culture at a later stage finally detected mycobacterium tuberculosis without the presence of pulmonary tuberculosis. Considering the current TB prevalence in the Southeast Asian region, it is crucial for otorhinolaryngologists to be aware of primary nasal TB when encountering unusual head and neck lesions, even in the absence of pulmonary TB.

Uncommon but Not Elusive: A Case of Syringocystadenoma Papilliferum in the External Auditory Canal

Ceruminous glands are modified apocrine sweat glands that are situated in the cartilaginous segment of the external auditory canal. Ceruminous gland tumors only account for about 5% to 5.7% of all external ear tumors. Syringocystadenoma papilliferum (SCAP) is a slow-growing and benign neoplasm that originates from the apocrine or eccrine sweat glands. It is also the rarest of all ceruminous gland neoplasms and only accounts for 2% of these cases. This is the 19th reported case of SCAP in the external auditory canal in the English literature. The definite diagnosis of SCAP is confirmed histologically due to varied differentials from its clinical appearance. The mainstay treatment of SCAP is surgical excision of the tumor, in our case, we obtained an incisional biopsy to aid in the diagnosis and then proceeded with an excisional biopsy. The patient has no signs of tumor recurrence post-operatively. A detailed review of the clinical, radiographic, and histomorphological characteristics of SCAP is discussed.

A Case of an Uncommon Lower Lip Swelling

A woman in her fifty-seventh year appeared with a painless swelling on her left lower lip that had been present for three years. The size of the swelling was noticeably increasing in size over time. On examination, there was a lump that was firm, non-tender, and measured 2 cm x 1 cm above the lower lip. The oral cavity, as well as the intraoral mucosa, were normal and unremarkable in appearance. As fine-needle aspiration cytology revealed a spindle cell lesion, she had an excision biopsy performed, followed by bilateral advancement flap closure. Histopathological examination (HPE) revealed a schwannoma in the tissue sample. Schwannomas are rare, benign neural tumors originating from Schwann cells. They are mainly asymptomatic and have a moderate rate of growth. Excision is the recommended treatment for schwannomas. Proper surgical planning and postoperative monitoring are crucial for optimal wound healing and complete recovery.

Nasal Septal Ancient Schwannoma: Ancient and Rare

Schwannoma is a rare benign neurogenic tumor arising from the Schwann cells of peripheral nerves. A 77-year-old man presented with progressively worsening left nasal block and hyposmia for the past six months. Nasal endoscopy revealed a polypoidal reddish mass occupying the left middle meatus. The biopsy was in favor of ancient schwannoma. Endoscopic transnasal excision of the mass arising from the left nasal septum was performed. A middle meatal antrostomy was also performed. The tumor cells were positive for S100 protein. Presenting symptoms are common to other sinonasal tumors, and the differential diagnoses include carcinoma, inverted papilloma, sarcoma, lymphoma, and neurofibroma. Schwannomas are composed of spindle cells with two histologically distinct patterns that can be mixed: Antoni type A and Antoni type B. A neural crest marker antigen, S-100 protein, is useful to corroborate our diagnosis. It is vital to consider nasal septal schwannoma in the differential diagnosis of patients complaining of unilateral nasal obstruction with polypoidal nasal mass, especially the posterior third of the nasal septum. Transnasal endoscopic surgery is the preferred approach for nasal septal schwannoma.

Uncommon Sites of Lymphoepithelial Carcinoma in Head and Neck Region

We present two cases of Lymphoepithelial carcinoma (LEC) which were found in uncommon sites, the first at the right parotid salivary gland and the second at the base of the tongue. Both patients presented with painless neck masses and were diagnosed with histologic analysis. There is an association with Epstein-Barr virus (EBV) infection in the first case, but none was found in the second case. The primary and metastatic LEC are indistinguishable through histological studies. Therefore, examination of nasopharynx and neck imaging is vital to differentiate primary and metastatic LEC in non-nasopharyngeal sites. A collaboration between surgeons and pathologists is essential for accurate diagnosis of LEC. Radiotherapy is the main choice of treatment for LEC, similar to the cases in the nasopharynx.

Malignant Transformation of Juvenile Recurrent Respiratory Papillomatosis

Malignant transformation of recurrent respiratory papillomatosis (RRP) is a rare entity occurring in only less than 5% of patients with RRP. The risk of transformation can arise even in the absence of risk factors such as smoking and radiation. We describe a patient with juvenile RRP diagnosed since childhood, who suffered malignant transformation into a squamous cell carcinoma after 29 years. Keywords: Recurrent respiratory papillomatosis; laryngeal neoplasms; squamous cell carcinoma; human papilloma-virus.

Parotid sialolithiasis and sialadenitis in a 3-year-old child: a case report and review of the literature

Background

Salivary gland calculi are common in adults but rare in the paediatric population. It accounts for only 3% of all cases of sialolithiasis. Parotid ductal calculus is rare as compared to submandibular ductal calculus.

Case presentation

A 3-year-old boy presented with acute painful right parotid swelling with pus discharge from the Stensen duct. Computed tomography revealed calculus obstructing the parotid duct causing proximal ductal dilatation and parotid gland and masseter muscle oedema. The child was treated with conservative measures, and subsequently the swelling and calculus resolved.

Conclusions

Small parotid duct calculus in children may be successfully treated with conservative measures which obviate the need for surgery. We discuss the management of parotid sialolithiasis in children and conduct literature search on the similar topic.