Raja Al'konee Raja Lope Ahmad

Rate of Recurrent Vestibular Schwannoma after Total Removal via Different Surgical Approaches

Objectives: The objective of this study was to assess the differences in the recurrence rates of vestibular schwannoma (VS) after total tumor removal through enlarged translabyrinthine (ETL), retrosigmoid (RS), and middle cranial fossa (MCF) approaches. Our results were compared with previously published data, and literature reviews were done to identify the possible causes for the recurrence of VS. Methods: We performed a retrospective analysis of 2,400 cases of VS that underwent removal at the Gruppo Otologico, Piacenza, Italy, from 1983 until 2010. The minimum postoperative follow-up was 12 months. We also reviewed the previously published data on recurrence rates of VS after ETL, RS, and MCF approaches. Results: Total tumor removal was achieved in 2,252 cases (93.8%). The recurrence rate was 0.05% for the ETL approach, 0.7% for the RS approach, and 1.8% for the MCF approach. Literature reviews of 3 previously published case series utilizing the translabyrinthine approach showed that none of the primary tumors were less than 2.0 cm in size. Recurrences were seen between 1 and 13 years after the initial surgery. Conclusions: The rate of VS recurrence after total removal is exceptionally low in experienced hands. Undetected microscopic deposits left on crucial points such as the facial nerve, the preserved cochlea nerve, or the fundus of the internal auditory canal could be possible causes for the recurrence. A definite advantage of an ETL approach is the excellent internal auditory canal exposure, resulting in an extremely low rate of VS recurrence. The patients should be followed up to 15 years with gadolinium-enhanced magnetic resonance imaging (with fat suppression sequence in ETL approach cases). Recurrent VS may exhibit a faster growth rate than primary VS.

Surgical Management of Juvenile Nasopharyngeal Angiofibroma Without Angiographic Embolization

Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign neoplasm that occurs almost exclusively in the nasopharynx of adolescent males. Surgery remains the primary treatment of choice. JNA has always presented a management challenge to surgeons because of its vascular nature, site of occurrence, and local tissue destruction. The surgical approaches are either standard open method which include external or intraoral incisions, or the recent advanced approach, i.e. via using the endonasal endoscope. It is widely accepted that the use of preoperative angiographic embolization reduces the occurrence of intraoperative bleeding and facilitates tumour removal. However, angiographic embolization is not available at all centres. The purpose of this article is to present our experience with five patients diagnosed with JNA who were resected without embolization, using various surgical approaches. Two tumours were removed via endonasal endoscopic surgery. None of the tumours were embolized prior to surgery. We highlight the preoperative evaluation of tumour extent, using both computed tomography (CT) and magnetic resonance angiography, and the importance of temporary clamping of the external carotid artery intraoperatively. Our results suggest that the latter procedure is a safe and effective means of facilitating surgery and reducing intraoperative bleeding.

Oncologic outcome in surgical management of jugular paraganglioma and factors influencing outcomes

The purpose of this study was to identify the factors that may influence the management outcome in patients with jugular paragangliomas.

The association between sleep apnea and young adults with hypertension

To study the association between sleep apnea and hypertension in a younger age group than previously studied, adding upper airway sizes at endoscopy as important compounding variables not often included in the past.

Contrecoup injury in patients with traumatic temporal bone fracture.

OBJECTIVE To study the prevalence and patterns of contrecoup injury in traumatic temporal bone fracture cases. METHOD A prospective, cohort study was undertaken of all patients with traumatic head injury admitted to a tertiary referral hospital in Malaysia within an 18-month period. High resolution computed tomography scans of the brain and skull base were performed in indicated cases, based on clinical findings and Glasgow coma score. Patients with a one-sided temporal bone fracture were selected and subsequent magnetic resonance imaging performed in all cases. Contrecoup injury incidence, type, severity and outcome were recorded. RESULTS Of 1579 head injury cases, 81 (5.1 per cent) met the inclusion criteria and were enrolled in the study. Temporal bone fractures were significantly associated with intracranial injuries (p < 0.001). The incidence of a contrecoup injury in cases with temporal bone fracture was 13.6 per cent. Contrecoup injury was significantly associated with petrous temporal bone fracture (p < 0.01). The commonest contrecoup injury was cerebral contusion, followed by extradural haematoma and subdural haematoma. CONCLUSION Contrecoup injury is not uncommon in cases of temporal bone fracture, and is significantly associated with petrous temporal bone fracture.

Predicting safe tonsillectomy for ambulatory surgery

OBJECTIVES To assess the safety of tonsillectomy procedure in local setting. METHODS Retrospective review of 267 tonsillectomy patients in Tengku Ampuan Afzan Hospital, Malaysia from January 2006 to December 2007. RESULTS Only 2.6% had trauma, 1.1% had difficult intubation, 0.7% had anaesthetic complication and none developed bleeding intra-operatively. Post-operatively, both primary and secondary haemorrhage showed prevalence of 1.9% each, 1.1% patients had infection and 0.4% patients had inability of extubation while another 1.9% had other complications. Duration of post-operative hospital stay was only slightly increased with occurrence of intra-operative complications but not with post-operative complications. Significant increase in risk was observed for both primary haemorrhage (OR: 1.05, 95% CI 1.01-1.09 min, P=0.020) and respiratory complications (OR: 1.08, 95% CI 1.01-1.16 min, P=0.024) by 4.5% and 8.3%, respectively, with every 1-min increase in length of surgery. CONCLUSIONS The observed low prevalence of complications corresponded with large number of studies denoting safety of tonsillectomy. This may well be increased by appropriately reducing the length of surgery. Although predictors for complications were unable to be determined, it is not advisable for ambulatory tonsillectomy to be performed on OSA patients considering the respiratory complications observed in our setting.

Tracheal agenesis as a rare cause of difficult intubation in a newborn with respiratory distress: a case report

IntroductionTracheal agenesis is a very rare congenital airway anomaly. It may pose a great challenge to the first attending physician both in diagnosis and in establishing the airway during the first day of life.Case presentationWe report a newborn Malay baby boy with trachea agenesis (type III by Floyds classification) who presented with severe respiratory distress immediately after birth. Clinical diagnosis in this case was not straightforward, as it started with difficulty in intubation followed by an unsuccessful emergency tracheostomy in the neonatal intensive care unit. Urgent surgical neck exploration with endoscopic examination in the general operating theatre revealed the final diagnosis. The authors present a short description of the embryopathology and diagnostic criteria of the abnormality.ConclusionWe hope this case presentation will be valuable in increasing the awareness of physicians about this rare cause of tracheal obstruction or difficult intubation.

Patterns of intracranial hemorrhage in petrous temporal bone fracture

OBJECTIVE To study the relationship pattern of intracranial hemorrhage in cases of traumatic petrous temporal bone fracture. METHODS All head injury cases admitted to the Emergency Department, Hospital Tengku Ampuan Afzan, Pahang, Malaysia in 2008 were assessed. Computerized tomography (CT) scan of the skull base was performed in indicated cases. Patients with a petrous temporal bone fracture were included in the study. Subsequent magnetic resonance imaging (MRI) was performed. Intracranial hemorrhages incidence, management and outcome were recorded. RESULTS From 1421 cases of head injury, 49(3.4%) patients were diagnosed to have a petrous bone fracture from the CT scan. Only 46 cases underwent MRI scan and were included in this study. Of these, 36(78.3%) cases had associated intracranial hemorrhages (p<0.01). Intracranial hemorrhage was associated with the longitudinal types of petrous fracture (p<0.05). Subdural hematoma was the most prevalent type of bleed (55.6%). There was no association between the types of intracranial bleeding (extradural, subdural, subarachnoid or intracerebral hemorrhage) and the types of petrous bone fracture (longitudinal, oblique or transverse). The mortality rate was 17.4%. The mortality cases were associated with the presence of other skull bone fractures (p<0.05). CONCLUSIONS Petrous fracture is significantly associated with intracranial hemorrhage. There was no association between the types of petrous fracture and the types of intracranial hemorrhages in our material.

Bilateral abductor vocal cord palsy and pregnancy: a case report

Introduction/backgroundBilateral abductor vocal cord palsy in pregnancy is a rareclinical problem. Due to the rarity of this condition, there isno definite guideline on obstetric management.CaseA 23-year-old primigravida was referred to our tertiaryhospital at 23 weeks gestation. Her prior antenatal care hadbeen with a primary health care clinic. She was diagnosedwith papillary carcinoma of the thyroid when she was17 years old, and had undergone a total thyroidectomy. Shehad since been in remission, and had been on thyroxine200 lg daily. She reported hoarseness of voice since herthyroidectomy, but did not have respiratory compromise.On presentation, she complained of stridor, snoring andworsening episodes of sleep apnoea since early in thesecond trimester. On examination, her pulse rate was88 bpm, her blood pressure was 120/80. Her respiratoryrate was 20/min. Stridor was audible even without aus-cultation. Auscultation of her lungs was unremarkable. Heruterus size corresponded to her dates and ultrasonographyrevealed a structurally normal foetus with normal growthparameters. She was then referred to an otorhinolaryngol-ogist for assessment. A flexible laryngoscopy showedbilateral abductor vocal cord palsy in paramedian position(Fig. 1).Her condition remained stable until 32 weeks when herstridor worsened and she was having more difficultybreathing. A decision was made to electively insert a tra-cheostomy at 36 weeks, and to perform a lower segmentcaesarean section at 38 weeks. However, ultrasonographyat 36 weeks showed evidence of intrauterine growthrestriction (IUGR) and an amniotic fluid index of 6.0.Under general anaesthesia, a size 7.5 tracheostomy tubewas inserted. At the same sitting, lower segment caesareansection was performed uneventfully. A baby girl weighing2,600 g was delivered with an Apgar score of 8 at 1 minand 9 at 5 min. Estimated blood loss was 400 ml. Twoweeks later, left laser cordectomy was performed followedby removal of the tracheostomy. On follow-up 2 weekslater, her voice was still hoarse but she no longer hadstridor.DiscussionAbductor vocal cord palsy is caused by damage to one orboth recurrent laryngeal nerves (RLN). RLN palsy is acommon complication following neck/thyroid surgery witha reported frequency of 6.6–13.2 % [1, 2]. The incidencefollowing thyroidectomy for thyroid carcinoma is 10.1 %[3]. In bilateral RLN palsy, the vocal cords remain in theparamedian position. It commonly presents as stridor andhoarseness of voice. It may occur due to direct or indirectsurgical denervation of the RLN, or it can happen due to

08:28: Traumatic Facial Nerve Palsy: The Outcome of Surgery

are not limited to the centra METHODS: Some 32 patients were randomized in order to obtain either temporal rTMS (10 sessions, 1Hz, left auditory cortex, 2000 pulses/d, 110% motor threshold) or a combination of temporal and prefrontal rTMS (10 sessions, at each session 20 Hz rTMS, left dorsolateral prefrontal cortex, 1,000 pulses/d, 110% motor threshold; followed by 1Hz, left auditory cortex, 1,000 pulses/d, 110% motor threshold). Tinnitus Severity was assessed before and after treatment and after a follow-up period of three months by using a standardized tinnitus questionnaire (TQ). RESULTS: Assessment of TQ score directly after therapy showed an improvement of the score for both groups but no differences between the two groups. Evaluation after three months revealed a remarkable advantage for the group of patients who received combined prefrontal and temporal rTMS. CONCLUSIONS: These results support recent data suggesting that auditory and nonauditory brain areas are involved in tinnitus pathophysiology. This should be considered in the development of future treatment strategies.