Aun Wee Chong

Velopharyngeal and choanal stenosis after radiotherapy for nasopharyngeal carcinoma

Choanal stenosis is a well recognized late complication of radiotherapy for nasopharyngeal carcinoma. However velopharyngeal stenosis post radiotherapy for nasopharyngeal carcinoma is rare. We present here a case of bilateral choanal stenosis and velopharyngeal stenosis in a patient treated with radiotherapy for nasopharyngeal carcinoma. A 58-year-old woman presented to our otolaryngology clinic with a one year history of nasal obstruction. She was diagnosed to have nasopharyngeal carcinoma 12 years ago for which she received radiotherapy. Clinical examination revealed bilateral choanal stenosis and velopharyngeal stenosis. Treatment of choanal stenosis and velopharyngeal stenosis is challenging due to high incidence of recurrence and patients frequently require multiple procedures. The patient underwent a transnasal endoscopic excision of velopharyngeal scar tissue and widening of posterior choana using Surgitron®, mitomycin-C applied topically to the surgical wound and bilateral stenting under general anesthesia. The stents were kept for two weeks, and 3 years post operation velopharyngeal aperture and posterior choana remained patent. As illustrated in this case velopharyngeal stenosis can occur after radiotheraphy and should not be overlooked. Combine modality of transnasal endoscopic excision of velopharyngeal scar tissue, widening of choanal stenosis with Surgitron® followed by the application of mitomycin-C and stenting has been shown to be an effective option.

Basaloid squamous cell carcinoma of the oropharynx: comparison of two cases and review of the literature.

We describe a rare case of BSCC in the retromolar trigone with only 3 other cases in the literature and also compare the differences between 2 cases of BSCC in terms of presentation and progression. The first patient had a markedly slower progression with painful retromolar trigone swelling over 4 months without nodal metastases. In contrast, the second patient gave a 2-week history of neck swelling with nodal involvement, indicating extremely rapid progression. Our management was tailored accordingly with the first patient undergoing intraoral excision of tumour and adjuvant radiotherapy while the other had bilateral neck dissection with postoperative chemoradiotherapy. Both patients achieved good outcome and are free from disease.

Pulmonary hypertension and echocardiogram parameters in obstructive sleep apnea

Obstructive sleep apnea (OSA) is a growing health hazard in the United States and worldwide. OSA is now recognized as a disorder with systemic manifestations and its association with obesity and adverse cardiovascular consequences. There is increasing evidence that OSA may be associated with systemic hypertension and an increased incidence of stroke, heart failure, myocardial infarction, and arrhythmias. Less information is available about the association between OSA and pulmonary hypertension (PH). We therefore conduct this study to look at the prevalence of the pulmonary hypertension in obstructive sleep apnea patient and to identify risk factors leading to pulmonary hypertension among OSA patient. We studied and analyzed all OSA patient confirmed by polysomnograph in the year 2015. Twenty-five patients with OSA were included in this study with prevalence of pulmonary hypertension of 16%. Univariate analysis of various factors revealed a statistically significant association between having the lowest SpO2 of <70% and pulmonary hypertension (p = 0.016). There were no statistically significant associations between age, gender, smoking status, hypertension, body mass index (BMI), or apnea–hypopnea index (AHI) with occurrence of pulmonary hypertension. AHI is not a good predictor for pulmonary hypertension. The real value of using AHI to predict the health risk of OSA is doubtful. We recommend routine echocardiogram among OSA patient. The objective information in the echocardiogram provides evidence for counseling of patient with disease of OSA and hence hopefully can improve compliance of patient to treatment especially usage of CPAP.

Fungal laryngitis causing airway compromise in post irradiated patient

Abstract Fungal laryngeal infection is commonly seen in immunocompromised individuals, and can mimic other laryngeal diseases like gastroesophageal reflux disease, granulomatous disease, leucoplakia and carcinoma. Therefore, it is important for correct initial diagnosis and treatment to avoid morbid consequences. We have reported a patient with laryngeal candidiasis who was previously diagnosed with laryngeal cancer and treated by concurrent chemoradiation therapy, presented with shortness of breath and stridor, requiring an emergency tracheostomy. Laryngoscopy examination revealed the presence of irregular mucosa at the posterior 2/3 of the left vocal cord extending to the left false cord and biopsy taken. Histopathological examination revealed necrotic tissue with colonies of bacteria and Actinomyces, and closer examination revealed fungal organisms exhibiting round, budding structures along with branching hyphae of varying sizes. Special histochemistry with Gomori Methenamine. Silver (GMS) and periodic acid-Schiff (PAS) stains confirmed the presence of fungal bodies. Tissue for culture and sensitivity grew Candida albicans, and the patient treated with IV fluconazole and discharge home with oral fluconazole. Post-treatment follow-up laryngoscopy examination revealed normal laryngeal mucosa with no evidence of fungal bodies or tumours recurrence. A conclusion can be made that diagnosis of a patient with fungal laryngitis requires early detection and treatment, as misdiagnosis or delay in treatment may result in further impairment to the anatomical and functional properties of the larynx. Invasive fungal infection can mimic or hide underlying concomitant laryngeal malignancies. Therefore, performing a biopsy during initial presentation allows the exclusion of underlying malignancy and further progression of the malignancy.

Iatrogenic tracheal flap mimicking tracheal stenosis with resultant stridor

OBJECTIVE To illustrate a case of an iatrogenic mucosal tear in the trachea which caused a one-way valve effect, obstructing the airway and manifesting as post-extubation stridor. CASE REPORT We report a case of iatrogenic tracheal mucosal tear secondary to violent movement during intubation. The patient presented with post-extubation stridor that worsened over three days. Initial evidence suggested tracheal stenosis. Computed tomography scans revealed a mucosal tear at the level of the seventh cervical to second thoracic vertebrae. The tear was caused by forceful inflow of air as breathing became more and more difficult, resulting in a false tract. A tracheostomy changed the direction of airflow, bypassing the tear. The inflated tracheostomy tube cuff acted as a stent to keep the flap in place as healing occurred. CONCLUSION Iatrogenic laryngotracheal injuries are common, especially when endotracheal intubation is performed under unfavourable emergency conditions. A tracheal mucosal tear is a rare entity which is almost always undiagnosed. However, a tracheal mucosal flap may be suspected when changes in patient position alter the nature and severity of the resultant stridor and/or respiratory distress. In such cases, an inflated tracheostomy tube cuff should be kept in place for an adequate period, to act as a stent and help keep the flap in place while healing occurs.